Basic Information
| Provider Information | |||||||||
| NPI: | 1760866891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERTOWN PHYSICIAN PRACTICES LLC | ||||||||
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| OtherOrganizationName: | WRMC DIRECTIONS COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530983334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202524800 | ||||||||
| FaxNumber: | 9202624813 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530983334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202524800 | ||||||||
| FaxNumber: | 9202624813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2015 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6159207514 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.