=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336222769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGY CLINIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2006
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 N BLACKHAWK AVE STE 212
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-238-9991
-----------------------------------------------------
Fax | 608-238-1929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 N BLACKHAWK AVE STE 212
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53705-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-238-9991
-----------------------------------------------------
Fax | 608-238-1929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/CO-DIRECTOR
-----------------------------------------------------
Name | DR. DAVID ROETHE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 608-280-6486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 1919
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------