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General NPI Number Information
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NPI Number | 1578196168
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Entity Type | Organization
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Legal Business Name | PSYCHOTHERAPY CENTER OF WAUNAKEE LLC
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Dates
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Enumeration Date | 02/21/2020
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Last Update Date | 02/21/2020
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Provider Practice Location Address
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Address Line | 110 BAKER ST STE C
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City | WAUNAKEE
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State | WI
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Zip | 53597-2707
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Country | US
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Telephone | 608-712-9362
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Fax |
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Provider Business Mailing Address
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Address Line | 928 LEXINGTON WAY
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City | WAUNAKEE
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State | WI
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Zip | 53597-2104
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Country | US
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Telephone | 608-712-9362
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JOHN RAYMOND WEISS
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Credential | MFT-IT
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Telephone | 608-712-9362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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