Provider Demographics
NPI:1356489256
Name:PLOVER PSYCHOLOGICAL CLINIC, LLC
Entity Type:Organization
Organization Name:PLOVER PSYCHOLOGICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:M
Authorized Official - Last Name:PALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-347-5570
Mailing Address - Street 1:2840 POST RD
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3443
Mailing Address - Country:US
Mailing Address - Phone:715-347-5570
Mailing Address - Fax:715-347-5560
Practice Address - Street 1:2840 POST RD
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-3443
Practice Address - Country:US
Practice Address - Phone:715-347-5570
Practice Address - Fax:715-347-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42243400Medicaid
WI=========012OtherBLUE CROSS CLINIC PROVIDE
WI00084042Medicare ID - Type UnspecifiedMEDICARE CLINIC PROVIDER