Healthcare Provider Details

I. General information

NPI: 1528232386
Provider Name (Legal Business Name): CHILDREN'S SERVICE SOCIETY OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 FORDEM AVE
MADISON WI
53704-4604
US

IV. Provider business mailing address

1716 FORDEM AVE
MADISON WI
53704-4604
US

V. Phone/Fax

Practice location:
  • Phone: 608-221-3511
  • Fax: 608-221-3514
Mailing address:
  • Phone: 608-221-3511
  • Fax: 608-221-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. RON PUPP
Title or Position: DIRECTOR OF COUNSELING
Credential: PHD
Phone: 414-231-4808