Provider Demographics
NPI:1124193065
Name:PEDIATRIC PSYCHOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:PEDIATRIC PSYCHOLOGY ASSOCIATES LLC
Other - Org Name:AUTISM BEHAVIORAL NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRITZL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, BCBA-D
Authorized Official - Phone:414-476-9755
Mailing Address - Street 1:3636 N 124TH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2125
Mailing Address - Country:US
Mailing Address - Phone:414-476-9755
Mailing Address - Fax:414-476-3413
Practice Address - Street 1:3636 N 124TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2125
Practice Address - Country:US
Practice Address - Phone:414-476-9755
Practice Address - Fax:414-476-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI613 057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42212500Medicaid