Healthcare Provider Details

I. General information

NPI: 1740794627
Provider Name (Legal Business Name): INTEGRATIVE PSYCHOLOGICAL CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 INTERNATIONAL LN STE 119
MADISON WI
53704-3154
US

IV. Provider business mailing address

2317 INTERNATIONAL LN STE 119
MADISON WI
53704-3154
US

V. Phone/Fax

Practice location:
  • Phone: 608-467-8870
  • Fax: 608-467-6735
Mailing address:
  • Phone: 608-467-8870
  • Fax: 608-467-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3043-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8396
License Number StateWI

VIII. Authorized Official

Name: DR. LESLEY BAIRD CHAPIN
Title or Position: OWNER
Credential: PSY.D.
Phone: 608-302-9752