Healthcare Provider Details

I. General information

NPI: 1659447704
Provider Name (Legal Business Name): JANESVILLE PSYCHIATRIC CLINIC MAIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W MILWAUKEE ST SUITE 206 & 207
JANESVILLE WI
53548-2998
US

IV. Provider business mailing address

15 W MILWAUKEE ST SUITE 206 & 207
JANESVILLE WI
53548-2998
US

V. Phone/Fax

Practice location:
  • Phone: 608-755-1475
  • Fax: 608-755-1733
Mailing address:
  • Phone: 608-755-1475
  • Fax: 608-755-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1448
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1448
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1448
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1448
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1448
License Number StateWI
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1448
License Number StateWI

VIII. Authorized Official

Name: MR. WILLIAM HOLLINGSWORTH
Title or Position: CLINIC DIRECTOR, OWNER
Credential:
Phone: 608-755-1475