Provider Demographics
NPI:1538684121
Name:WISCONSIN THERAPY CENTER LLC
Entity Type:Organization
Organization Name:WISCONSIN THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:THIMM-JURADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-9770
Mailing Address - Street 1:PO BOX 14421
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53708-0421
Mailing Address - Country:US
Mailing Address - Phone:608-833-9770
Mailing Address - Fax:608-833-1197
Practice Address - Street 1:402 GAMMON PL STE 290
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1075
Practice Address - Country:US
Practice Address - Phone:608-833-9770
Practice Address - Fax:608-833-1197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2414-121041C0700X
261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty