MEDICARE: WISCONSIN THERAPY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
3	261QM0850X	Adult Mental Health Clinic/Center
4	1041C0700X	Clinical Social Worker	2414-12	WI

General Provider Information

NPI Number	:	1538684121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 14421
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53708-0421
Country	:	US
Telephone Number	:	608-833-9770
Fax Number	:	608-833-1197

Provider Business Practice Location Address
First Line	:	402 GAMMON PL STE 290
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1075
Country	:	US
Telephone Number	:	608-833-9770
Fax Number	:	608-833-1197

Authorized Official
Title or Position	:	OWNER
Name	:	LUCINDA THIMM-JURADO
Credential	:
Telephone Number	:	608-833-9770

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	08/04/2017

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