Basic Information
| Provider Information | |||||||||
| NPI: | 1841413879 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOURNEY MENTAL HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 KESSEL CT | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802695 | ||||||||
| FaxNumber: | 6082802705 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 KESSEL CT | ||||||||
| Address2: | SUITE 49 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802695 | ||||||||
| FaxNumber: | 6082802705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | NEITZEL | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR BUSINESS DEVELOP | ||||||||
| AuthorizedOfficialTelephone: | 6082802695 | ||||||||
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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 | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 42108400 | 05 | WI | MEDICAID |