Healthcare Provider Details

I. General information

NPI: 1164423000
Provider Name (Legal Business Name): JOSEPH J COLLETTI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N BLACKHAWK AVE SUITE 100
MADISON WI
53705-3357
US

IV. Provider business mailing address

702 N BLACKHAWK AVE SUITE 100
MADISON WI
53705-3357
US

V. Phone/Fax

Practice location:
  • Phone: 608-663-5449
  • Fax: 608-663-5928
Mailing address:
  • Phone: 608-663-5449
  • Fax: 608-663-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2092057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: