Healthcare Provider Details

I. General information

NPI: 1285676593
Provider Name (Legal Business Name): MIDLANDS PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 LODI ST
LODI WI
53555-1418
US

IV. Provider business mailing address

336 LODI ST
LODI WI
53555-1418
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-2080
  • Fax: 608-592-7120
Mailing address:
  • Phone: 608-592-2080
  • Fax: 608-592-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateWI

VIII. Authorized Official

Name: RONALD BRUCE JOHNSON
Title or Position: OWNER/PARTNER
Credential: PHD
Phone: 608-592-2080