Provider Demographics
NPI:1285676593
Name:MIDLANDS PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MIDLANDS PSYCHOLOGICAL ASSOCIATES, LLC
Other - Org Name:MIDLANDS PSCHOLOGICAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-592-2080
Mailing Address - Street 1:336 LODI ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1418
Mailing Address - Country:US
Mailing Address - Phone:608-592-2080
Mailing Address - Fax:608-592-7120
Practice Address - Street 1:336 LODI ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1418
Practice Address - Country:US
Practice Address - Phone:608-592-2080
Practice Address - Fax:608-592-7120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
44371Medicare PIN