Healthcare Provider Details

I. General information

NPI: 1437106036
Provider Name (Legal Business Name): MENDOTA MENTAL HEALTH INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 TROY DR
MADISON WI
53704-1521
US

IV. Provider business mailing address

301 TROY DR
MADISON WI
53704-1521
US

V. Phone/Fax

Practice location:
  • Phone: 608-301-1504
  • Fax: 608-301-1538
Mailing address:
  • Phone: 608-301-1504
  • Fax: 608-301-1538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number24251-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY J VAN RYBROECK
Title or Position: DIRECTOR
Credential: PHD, JD
Phone: 608-301-1042