Provider Demographics
NPI:1336222769
Name:PSYCHOLOGY CLINIC INC.
Entity Type:Organization
Organization Name:PSYCHOLOGY CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/CO-DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROETHE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:608-280-6486
Mailing Address - Street 1:310 N MIDVALE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:608-852-8585
Mailing Address - Fax:608-238-1929
Practice Address - Street 1:310 N MIDVALE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3265
Practice Address - Country:US
Practice Address - Phone:608-852-8585
Practice Address - Fax:608-238-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1919261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42161100Medicaid
WI42161100Medicaid