Healthcare Provider Details

I. General information

NPI: 1861803512
Provider Name (Legal Business Name): INTERPERSONNEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WISCONSIN AVE
MADISON WI
53703-1487
US

IV. Provider business mailing address

2205 COMMONWEALTH AVE
MADISON WI
53726-5301
US

V. Phone/Fax

Practice location:
  • Phone: 608-345-2273
  • Fax: 608-256-5116
Mailing address:
  • Phone: 608-345-2273
  • Fax: 608-256-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4026123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4026126
License Number StateWI

VIII. Authorized Official

Name: MS. HOLLY JORGENSON
Title or Position: OWNER
Credential: LCSW
Phone: 608-345-2273