Provider Demographics
NPI:1184893752
Name:PSYCHOTHERAPY & GROWTH CENTER
Entity type:Organization
Organization Name:PSYCHOTHERAPY & GROWTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LAUREE
Authorized Official - Last Name:SCHUTT-CHARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-770-7792
Mailing Address - Street 1:660 W WASHINGTON AVE
Mailing Address - Street 2:SUITE #307
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4703
Mailing Address - Country:US
Mailing Address - Phone:608-255-0669
Mailing Address - Fax:608-255-0667
Practice Address - Street 1:660 W WASHINGTON AVE
Practice Address - Street 2:SUITE #307
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-4703
Practice Address - Country:US
Practice Address - Phone:608-255-0669
Practice Address - Fax:608-255-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1393123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42164400Medicaid