Provider Demographics
NPI:1669676722
Name:PSYCHOLOGIE CLINIQUE SC
Entity Type:Organization
Organization Name:PSYCHOLOGIE CLINIQUE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:AMELIE
Authorized Official - Last Name:DELAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-437-4490
Mailing Address - Street 1:130 E WALNUT ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4239
Mailing Address - Country:US
Mailing Address - Phone:920-437-4490
Mailing Address - Fax:920-437-4492
Practice Address - Street 1:130 E WALNUT ST
Practice Address - Street 2:SUITE 410
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4239
Practice Address - Country:US
Practice Address - Phone:920-437-4490
Practice Address - Fax:920-437-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1530251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1530OtherLICENSED PSYCHOLOGIST
VA0810003479OtherLICENSED CLINICAL PSYCHOL
VA0810003479OtherLICENSED CLINICAL PSYCHOL
WI44284Medicare ID - Type Unspecified