Basic Information
Provider Information | |||||||||
NPI: | 1689770497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH PSYCHOLOGY ASSOCIATES, S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 N. BAYSHORE DR | ||||||||
Address2: | SUITE B230 | ||||||||
City: | GLENDALE | ||||||||
State: | WI | ||||||||
PostalCode: | 532174503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149624048 | ||||||||
FaxNumber: | 4149624052 | ||||||||
Practice Location | |||||||||
Address1: | 5800 N. BAYSHORE DR | ||||||||
Address2: | SUITE B230 | ||||||||
City: | GLENDALE | ||||||||
State: | WI | ||||||||
PostalCode: | 532174503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149624048 | ||||||||
FaxNumber: | 4149624052 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FULLER | ||||||||
AuthorizedOfficialFirstName: | ELLEN | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4149624048 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 104100000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 2084P0800X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.