Provider Demographics
NPI:1598149403
Name:JANESVILLE PSYCHIATRIC CLINIC OF MAIN
Entity type:Organization
Organization Name:JANESVILLE PSYCHIATRIC CLINIC OF MAIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HOLLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:608-436-6161
Mailing Address - Street 1:2010 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-6613
Mailing Address - Country:US
Mailing Address - Phone:608-436-6161
Mailing Address - Fax:
Practice Address - Street 1:2010 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-6613
Practice Address - Country:US
Practice Address - Phone:608-436-6161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JANESVILLE PSYCHIATRIC CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-10
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI162 - 124, 366 - 125251S00000X
WI3044- 123251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health