MEDICARE: DR. JOSEPH J COLLETTI PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2092057	WI

General Provider Information

NPI Number	:	1164423000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH J COLLETTI PHD

Provider Business Mailing Address
First Line	:	702 N BLACKHAWK AVE
Second Line	:	SUITE 100
City	:	MADISON
State	:	WI
Zip	:	53705-3357
Country	:	US
Telephone Number	:	608-663-5449
Fax Number	:	608-663-5928

Provider Business Practice Location Address
First Line	:	702 N BLACKHAWK AVE
Second Line	:	SUITE 100
City	:	MADISON
State	:	WI
Zip	:	53705-3357
Country	:	US
Telephone Number	:	608-663-5449
Fax Number	:	608-663-5928

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	04/21/2014

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