Provider Demographics
NPI:1659447704
Name:JANESVILLE PSYCHIATRIC CLINIC MAIN INC
Entity Type:Organization
Organization Name:JANESVILLE PSYCHIATRIC CLINIC MAIN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC 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 1:15 W MILWAUKEE ST
Mailing Address - Street 2:SUITE 206 & 207
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2998
Mailing Address - Country:US
Mailing Address - Phone:608-755-1475
Mailing Address - Fax:608-755-1733
Practice Address - Street 1:15 W MILWAUKEE ST
Practice Address - Street 2:SUITE 206 & 207
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2998
Practice Address - Country:US
Practice Address - Phone:608-755-1475
Practice Address - Fax:608-755-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1448101YA0400X, 101YM0800X, 103T00000X, 103TC2200X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659447704Medicaid
WI42123800Medicaid
WV43007200Medicaid
WIB53373Medicare UPIN
WI1659447704Medicaid