Provider Demographics
NPI:1053941666
Name:212 PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:212 PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:KC
Authorized Official - Last Name:HISER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-516-4347
Mailing Address - Street 1:7109 BRINDLEY CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2128
Mailing Address - Country:US
Mailing Address - Phone:608-516-4347
Mailing Address - Fax:
Practice Address - Street 1:7109 BRINDLEY CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2128
Practice Address - Country:US
Practice Address - Phone:608-205-8650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43741200Medicaid
WI100098189Medicaid