Provider Demographics
NPI:1619156502
Name:CLINICAL PSYCHOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CLINICAL PSYCHOLOGY ASSOCIATES, LLC
Other - Org Name:CLINICAL PSYCHOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-763-9191
Mailing Address - Street 1:197 W CHESTNUT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1200
Mailing Address - Country:US
Mailing Address - Phone:262-763-9191
Mailing Address - Fax:262-763-7767
Practice Address - Street 1:197 W CHESTNUT ST STE 100
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1200
Practice Address - Country:US
Practice Address - Phone:262-763-9191
Practice Address - Fax:262-763-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 261QM0801X
WI1588103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42171100Medicaid