Provider Demographics
NPI:1346446259
Name:WISCONSIN PSYCHOLOGICAL CENTER
Entity Type:Organization
Organization Name:WISCONSIN PSYCHOLOGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCELO
Authorized Official - Middle Name:
Authorized Official - Last Name:TRINIDAD-CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-270-1800
Mailing Address - Street 1:PO BOX 930406
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-0406
Mailing Address - Country:US
Mailing Address - Phone:608-270-1800
Mailing Address - Fax:608-270-9731
Practice Address - Street 1:49 KESSEL CT
Practice Address - Street 2:SUITE 204
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-6275
Practice Address - Country:US
Practice Address - Phone:608-270-1800
Practice Address - Fax:608-270-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2648103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty