Provider Demographics
NPI:1073687349
Name:RIVERWALK PSYCHOTHERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:RIVERWALK PSYCHOTHERAPY ASSOCIATES, LLC
Other - Org Name:MIDWEST CENTER FOR HUMAN SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:CLARDIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-224-0800
Mailing Address - Street 1:1110 N. OLD WORLD THIRD ST.
Mailing Address - Street 2:SUITE 401
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203
Mailing Address - Country:US
Mailing Address - Phone:608-423-3960
Mailing Address - Fax:608-423-7166
Practice Address - Street 1:1110 N. OLD WORLD THIRD ST.
Practice Address - Street 2:SUITE 401
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203
Practice Address - Country:US
Practice Address - Phone:414-224-0800
Practice Address - Fax:414-224-0883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42184700Medicaid
WI42184700Medicaid