Provider Demographics
NPI:1982064366
Name:MADISON NEUROPSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:MADISON NEUROPSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:608-841-1606
Mailing Address - Street 1:6510 GRAND TETON PLZ STE 102
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1031
Mailing Address - Country:US
Mailing Address - Phone:608-841-1606
Mailing Address - Fax:608-492-2573
Practice Address - Street 1:6510 GRAND TETON PLZ STE 102
Practice Address - Street 2:STE 24
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-841-1606
Practice Address - Fax:608-492-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3198-57103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty