=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073849717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONONA MEDIATION AND COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2009
-----------------------------------------------------
Last Update Date | 10/31/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6320 MONONA DR STE 314
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53716-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-442-3420
-----------------------------------------------------
Fax | 608-443-3421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6320 MONONA DR STE 314
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53716-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-442-3420
-----------------------------------------------------
Fax | 608-443-3421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER-PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KENNETH HUGH WALDRON
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 608-442-3420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 913-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1774-057
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------