Basic Information
| Provider Information | |||||||||
| NPI: | 1770688970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMAGINE A CHILD'S CAPACITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2875 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537133114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082046242 | ||||||||
| FaxNumber: | 6082046249 | ||||||||
| Practice Location | |||||||||
| Address1: | 2875 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537133114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082046242 | ||||||||
| FaxNumber: | 6082046249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR. | ||||||||
| AuthorizedOfficialTelephone: | 6083161127 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CEO. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 2251P0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 235500000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | 235Z00000X | WI | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 253Z00000X | WI | N | Agencies | In Home Supportive Care | 261QR0400X | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 41225100 | 05 | WI | MEDICAID |