Provider Demographics
NPI:1588175889
Name:EATING DISORDER SUPPORT NETWORK
Entity Type:Organization
Organization Name:EATING DISORDER SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-843-7055
Mailing Address - Street 1:429 GAMMON PL STE 200
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1053
Mailing Address - Country:US
Mailing Address - Phone:608-843-7055
Mailing Address - Fax:608-821-0938
Practice Address - Street 1:429 GAMMON PL STE 200
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1053
Practice Address - Country:US
Practice Address - Phone:608-843-7055
Practice Address - Fax:608-821-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5147-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty