Provider Demographics
NPI:1194252742
Name:WELLQOR PSYCHOLOGICAL SERVICES OF WISCONSIN, S.C.
Entity type:Organization
Organization Name:WELLQOR PSYCHOLOGICAL SERVICES OF WISCONSIN, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WOYTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:516-987-4200
Mailing Address - Street 1:135 PINELAWN RD STE 204N
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 PINELAWN RD STE 204N
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3133
Practice Address - Country:US
Practice Address - Phone:844-888-0355
Practice Address - Fax:844-222-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty