Healthcare Provider Details

I. General information

NPI: 1073849717
Provider Name (Legal Business Name): MONONA MEDIATION AND COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2009
Last Update Date: 10/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 MONONA DR STE 314
MONONA WI
53716-3985
US

IV. Provider business mailing address

6320 MONONA DR STE 314
MONONA WI
53716-3985
US

V. Phone/Fax

Practice location:
  • Phone: 608-442-3420
  • Fax: 608-443-3421
Mailing address:
  • Phone: 608-442-3420
  • Fax: 608-443-3421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1774-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number913-123
License Number StateWI

VIII. Authorized Official

Name: DR. KENNETH HUGH WALDRON
Title or Position: OWNER-PSYCHOLOGIST
Credential: PH.D.
Phone: 608-442-3420