Healthcare Provider Details

I. General information

NPI: 1821878414
Provider Name (Legal Business Name): CIVITAS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 W WASHINGTON AVE STE 310
MADISON WI
53703-4703
US

IV. Provider business mailing address

660 W WASHINGTON AVE STE 310
MADISON WI
53703-4703
US

V. Phone/Fax

Practice location:
  • Phone: 949-620-1831
  • Fax:
Mailing address:
  • Phone: 949-620-1831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MEGAN FITZPATRICK
Title or Position: OWNER
Credential: MS
Phone: 608-620-1831