Basic Information
| Provider Information | |||||||||
| NPI: | 1821141540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHIATRIC ASSOCIATES COUNSELING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 206 | ||||||||
| Address2: | 122 W SOUTH ST | ||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546650206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086372511 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546650206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086372511 | ||||||||
| FaxNumber: | 6086377921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOTH | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6086372511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1754 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 42167000 | 05 | WI | MEDICAID |