Provider Demographics
NPI:1225138126
Name:COMMUNITY PSYCHOLOGICAL SERVICES OF WAUPUN LLC
Entity Type:Organization
Organization Name:COMMUNITY PSYCHOLOGICAL SERVICES OF WAUPUN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:DEYOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:920-324-4358
Mailing Address - Street 1:1208 S WATERTOWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2309
Mailing Address - Country:US
Mailing Address - Phone:920-324-4358
Mailing Address - Fax:920-324-4737
Practice Address - Street 1:1208 S WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2309
Practice Address - Country:US
Practice Address - Phone:920-324-4358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1228261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42127800Medicaid
WI88800Medicare ID - Type Unspecified
WI42127800Medicaid