Healthcare Provider Details

I. General information

NPI: 1528510633
Provider Name (Legal Business Name): EAU CLAIRE PSYCHOLOGISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N FARWELL ST STE. 204
EAU CLAIRE WI
54703-3765
US

IV. Provider business mailing address

101 N FARWELL ST STE. 204
EAU CLAIRE WI
54703-3765
US

V. Phone/Fax

Practice location:
  • Phone: 715-514-4600
  • Fax: 715-514-4008
Mailing address:
  • Phone: 715-514-4600
  • Fax: 715-514-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1783-57
License Number StateWI

VIII. Authorized Official

Name: ANTON C SMETS
Title or Position: PARTNER
Credential: PH.D., PSY.D.
Phone: 715-514-4600