Provider Demographics
NPI:1134306103
Name:PROFESSIONAL PSYCHOLOGICAL SERVICES, SC
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHOLOGICAL SERVICES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STOLLDORF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-767-0440
Mailing Address - Street 1:441 MILWAUKEE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1230
Mailing Address - Country:US
Mailing Address - Phone:262-767-0440
Mailing Address - Fax:262-767-0777
Practice Address - Street 1:441 MILWAUKEE AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1230
Practice Address - Country:US
Practice Address - Phone:262-767-0440
Practice Address - Fax:262-767-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1746251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42155900Medicaid