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General NPI Number Information
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NPI Number | 1891568002
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Entity Type | Organization
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Legal Business Name | GREENBUSH PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 10/31/2023
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 541 S RANDALL AVE
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City | MADISON
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State | WI
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Zip | 53715-1653
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Country | US
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Telephone | 608-963-1380
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Fax |
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Provider Business Mailing Address
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Address Line | 6580 MONONA DR # 1153
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City | MONONA
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State | WI
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Zip | 53716-4032
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | JESSICA MARIE BROOKS
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Credential |
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Telephone | 608-963-1380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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