Provider Demographics
NPI:1598981318
Name:MOONTREE PSYCHOTHERAPY CENTER, LLC
Entity Type:Organization
Organization Name:MOONTREE PSYCHOTHERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-256-5115
Mailing Address - Street 1:401 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1487
Mailing Address - Country:US
Mailing Address - Phone:608-256-5115
Mailing Address - Fax:608-256-5116
Practice Address - Street 1:401 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1487
Practice Address - Country:US
Practice Address - Phone:608-256-5115
Practice Address - Fax:608-256-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1916261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42174900Medicaid
WI84950OtherWPS
WI84950OtherWPS
WI42174900Medicaid