Basic Information
| Provider Information | |||||||||
| NPI: | 1528232386 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S SERVICE SOCIETY OF WISCONSIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1716 FORDEM AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082213511 | ||||||||
| FaxNumber: | 6082213514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1716 FORDEM AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537044604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082213511 | ||||||||
| FaxNumber: | 6082213514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | PUPP | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COUNSELING | ||||||||
| AuthorizedOfficialTelephone: | 4142314808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 42115300 | 05 | WI | MEDICAID |