Basic Information
| Provider Information | |||||||||
| NPI: | 1407143308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL HEALTH CENTER OF DANE COUNTY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 W WASHINGTON AVE | ||||||||
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| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537032637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1848 HWY MM | ||||||||
| Address2: | CAMBODIAN TEMPLE | ||||||||
| City: | FITCHBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535752117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 11/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | NEITZEL | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6082802678 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 42216100 | 05 | WI | MEDICAID |