Provider Demographics
NPI:1295957512
Name:MADISON PSYCHOTHERAPY ASSOCIATES, INC.
Entity type:Organization
Organization Name:MADISON PSYCHOTHERAPY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GHILARDI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-251-0839
Mailing Address - Street 1:1912 ATWOOD AVE
Mailing Address - Street 2:SUITE #5
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5461
Mailing Address - Country:US
Mailing Address - Phone:608-251-0839
Mailing Address - Fax:608-255-2752
Practice Address - Street 1:1912 ATWOOD AVE
Practice Address - Street 2:SUITE #5
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5461
Practice Address - Country:US
Practice Address - Phone:608-251-0839
Practice Address - Fax:608-255-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1552261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42112900Medicaid