Provider Demographics
NPI:1720132806
Name:HARBOR COMMUNITY PSYCHOLOGICAL ASSOCIATES SC
Entity Type:Organization
Organization Name:HARBOR COMMUNITY PSYCHOLOGICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROOS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:630-541-5040
Mailing Address - Street 1:PO BOX 5714
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-5714
Mailing Address - Country:US
Mailing Address - Phone:920-606-8734
Mailing Address - Fax:866-201-3050
Practice Address - Street 1:2701 LARSEN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4863
Practice Address - Country:US
Practice Address - Phone:920-606-8734
Practice Address - Fax:866-201-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1598-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI84700OtherPTAN