Provider Demographics
NPI:1164587150
Name:FAMILY THERAPY CENTER OF MADISON, INC.
Entity Type:Organization
Organization Name:FAMILY THERAPY CENTER OF MADISON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-276-9191
Mailing Address - Street 1:700 RAY O VAC DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2479
Mailing Address - Country:US
Mailing Address - Phone:608-276-9191
Mailing Address - Fax:608-276-9144
Practice Address - Street 1:700 RAY O VAC DR
Practice Address - Street 2:SUITE 220
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2479
Practice Address - Country:US
Practice Address - Phone:608-276-9191
Practice Address - Fax:608-276-9144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42111900Medicaid
WI42111900Medicaid