Provider Demographics
NPI:1063804870
Name:MADISON PSYCHOTHERAPY CENTER, LLC
Entity type:Organization
Organization Name:MADISON PSYCHOTHERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC
Authorized Official - Phone:608-233-3037
Mailing Address - Street 1:702 N BLACKHAWK AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3357
Mailing Address - Country:US
Mailing Address - Phone:608-233-3037
Mailing Address - Fax:608-233-5893
Practice Address - Street 1:702 N BLACKHAWK AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:608-233-3037
Practice Address - Fax:608-233-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902023435Medicaid
WI1902023435Medicare UPIN