Provider Demographics
NPI:1326469750
Name:CONNECTIONS FOR GROWTH, PSYCHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:CONNECTIONS FOR GROWTH, PSYCHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSANNE
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:POE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-492-2474
Mailing Address - Street 1:N6404 EAST PARADISE RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2632
Mailing Address - Country:US
Mailing Address - Phone:262-637-8488
Mailing Address - Fax:262-637-8488
Practice Address - Street 1:5200 WASHINGTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4238
Practice Address - Country:US
Practice Address - Phone:262-637-8488
Practice Address - Fax:262-637-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1302-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39083800Medicaid