Provider Demographics
NPI:1073849717
Name:MONONA MEDIATION AND COUNSELING LLC
Entity Type:Organization
Organization Name:MONONA MEDIATION AND COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-442-3420
Mailing Address - Street 1:6320 MONONA DR STE 314
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3985
Mailing Address - Country:US
Mailing Address - Phone:608-442-3420
Mailing Address - Fax:608-443-3421
Practice Address - Street 1:6320 MONONA DR STE 314
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3985
Practice Address - Country:US
Practice Address - Phone:608-442-3420
Practice Address - Fax:608-443-3421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-31
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1774-057103T00000X
WI913-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty