Basic Information
| Provider Information | |||||||||
| NPI: | 1902430465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWMAN | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ED.S., NCSP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORELLO | ||||||||
| OtherFirstName: | TAYLOR | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 303 S PATERSON ST STE 1A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537034534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085710558 | ||||||||
| FaxNumber: | 6088075675 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S PATERSON ST STE 1A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537034534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085710558 | ||||||||
| FaxNumber: | 6088075675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 916-58 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | School |
ID Information
| ID | Type | State | Issuer | Description | 916-58 | 01 | WI | THE STATE OF WISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES | OTHER |