Provider Demographics
NPI:1487648663
Name:CREDENCE THERAPY ASSOCIATES INC
Entity Type:Organization
Organization Name:CREDENCE THERAPY ASSOCIATES INC
Other - Org Name:CREDENCE THERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STEEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-723-3424
Mailing Address - Street 1:1 1/2 W GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1722
Mailing Address - Country:US
Mailing Address - Phone:262-723-3424
Mailing Address - Fax:262-723-8308
Practice Address - Street 1:1 1/2 W GENEVA ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1722
Practice Address - Country:US
Practice Address - Phone:262-723-3424
Practice Address - Fax:262-723-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1262261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI538578OtherDEAN CARE
17257700OtherMAGELLAN BEH HEALTH
42168400OtherCENPATICO
WI42168400Medicaid
WI42169400OtherHIRSP
17257700OtherMAGELLAN BEH HEALTH
17257700OtherMAGELLAN BEH HEALTH