Provider Demographics
NPI:1528232386
Name:CHILDREN'S SERVICE SOCIETY OF WISCONSIN
Entity Type:Organization
Organization Name:CHILDREN'S SERVICE SOCIETY OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COUNSELING
Authorized Official - Prefix:DR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:PUPP
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-231-4808
Mailing Address - Street 1:1716 FORDEM AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4604
Mailing Address - Country:US
Mailing Address - Phone:608-221-3511
Mailing Address - Fax:608-221-3514
Practice Address - Street 1:1716 FORDEM AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4604
Practice Address - Country:US
Practice Address - Phone:608-221-3511
Practice Address - Fax:608-221-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42115300Medicaid