Healthcare Provider Details

I. General information

NPI: 1154520203
Provider Name (Legal Business Name): RIVERSIDE PSYCHIATRIC GROUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 ANGELS PATH RD
DE PERE WI
54115-4050
US

IV. Provider business mailing address

1325 ANGELS PATH RD
DE PERE WI
54115-4050
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-2855
  • Fax: 920-338-9270
Mailing address:
  • Phone: 920-338-2855
  • Fax: 920-338-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateWI
# 8
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HOWARD W DAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 920-338-2800