Provider Demographics
NPI:1578737706
Name:JANESVILLE PSYCHIATRIC CLINIC DAYTREATMENT FOR CHILDREN
Entity Type:Organization
Organization Name:JANESVILLE PSYCHIATRIC CLINIC DAYTREATMENT FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-755-1475
Mailing Address - Street 1:2640 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0231
Mailing Address - Country:US
Mailing Address - Phone:608-755-1475
Mailing Address - Fax:608-755-1733
Practice Address - Street 1:2640 MILTON AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0231
Practice Address - Country:US
Practice Address - Phone:608-755-1475
Practice Address - Fax:608-755-1733
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JANESVILLE PSYCHIATIC CLINIC MAIN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43007200Medicaid