Healthcare Provider Details

I. General information

NPI: 1063804870
Provider Name (Legal Business Name): MADISON PSYCHOTHERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N BLACKHAWK AVE SUITE 205
MADISON WI
53705-3357
US

IV. Provider business mailing address

702 N BLACKHAWK AVE SUITE 205
MADISON WI
53901-3357
US

V. Phone/Fax

Practice location:
  • Phone: 608-233-3037
  • Fax: 608-233-5893
Mailing address:
  • Phone: 608-233-3037
  • Fax: 608-233-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY ELLEN MILLER
Title or Position: CLINIC DIRECTOR
Credential: MS LPC
Phone: 608-233-3037