Provider Demographics
NPI:1992920300
Name:PSYCHOLOGICAL CONSULATNTS S.C.
Entity type:Organization
Organization Name:PSYCHOLOGICAL CONSULATNTS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:URSULA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-437-3854
Mailing Address - Street 1:130 E. WALUNT STREET
Mailing Address - Street 2:604
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-437-3854
Mailing Address - Fax:920-437-7488
Practice Address - Street 1:130 E. WALUNT STREET
Practice Address - Street 2:604
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-437-3854
Practice Address - Fax:920-437-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2463-057103TC0700X
WI1042103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42120100Medicaid