Healthcare Provider Details

I. General information

NPI: 1982064366
Provider Name (Legal Business Name): MADISON NEUROPSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 GRAND TETON PLZ STE 102 STE 24
MADISON WI
53719
US

IV. Provider business mailing address

6510 GRAND TETON PLZ STE 102
MADISON WI
53719-1031
US

V. Phone/Fax

Practice location:
  • Phone: 608-841-1606
  • Fax: 608-492-2573
Mailing address:
  • Phone: 608-841-1606
  • Fax: 608-492-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3198-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3198-57
License Number StateWI

VIII. Authorized Official

Name: DR. SARAH E PORTER
Title or Position: OWNER
Credential: PSYD
Phone: 608-841-1606