Healthcare Provider Details

I. General information

NPI: 1144551664
Provider Name (Legal Business Name): CHILDHOOD AUTISM THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N1563 COUNTY ROAD H
PALMYRA WI
53156-9738
US

IV. Provider business mailing address

N1563 COUNTY ROAD H
PALMYRA WI
53156-9738
US

V. Phone/Fax

Practice location:
  • Phone: 262-370-5527
  • Fax: 262-495-8689
Mailing address:
  • Phone: 262-370-5527
  • Fax: 262-495-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2387-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2387-57
License Number StateWI

VIII. Authorized Official

Name: DR. COLLEEN A RYAN
Title or Position: DIRECTOR
Credential: PHD
Phone: 262-370-7744