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General NPI Number Information
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NPI Number | 1346446259
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Entity Type | Organization
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Legal Business Name | WISCONSIN PSYCHOLOGICAL CENTER
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Dates
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Enumeration Date | 06/26/2007
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 49 KESSEL CT SUITE 204
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City | MADISON
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State | WI
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Zip | 53711-6275
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Country | US
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Telephone | 608-270-1800
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Fax | 608-270-9731
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Provider Business Mailing Address
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Address Line | PO BOX 930406
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City | VERONA
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State | WI
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Zip | 53593-0406
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Country | US
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Telephone | 608-270-1800
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Fax | 608-270-9731
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. MARCELO TRINIDAD-CARRILLO
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Credential | PH.D.
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Telephone | 608-270-1800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2648
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License Number State | WI
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