Healthcare Provider Details

I. General information

NPI: 1194252742
Provider Name (Legal Business Name): WELLQOR PSYCHOLOGICAL SERVICES OF WISCONSIN, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PINELAWN RD STE 204N
MELVILLE NY
11747-3133
US

IV. Provider business mailing address

135 PINELAWN RD STE 204N
MELVILLE NY
11747-3133
US

V. Phone/Fax

Practice location:
  • Phone: 844-888-0355
  • Fax: 844-222-4005
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: CONSTANCE LEE WOYTHAL
Title or Position: OWNER
Credential: PSYD
Phone: 516-987-4200