MEDICARE: WATER TIGER PSYCHOTHERAPY, LLC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1922701812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATER TIGER PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	100 WILBURN RD STE 100
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1478
Country	:	US
Telephone Number	:	920-215-1254
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 ATWOOD AVE STE 217
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-5382
Country	:	US
Telephone Number	:	920-215-1254
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SARA TODD
Credential	:	LCSW
Telephone Number	:	920-215-1254

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	09/09/2023

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