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101 E Main St Ste 4 Waunakee WI 53597-1196 | |
| (608) 886-9023 | |
| (608) 200-2417 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 101 E Main St Ste 4, Waunakee, Wisconsin |
| Authorized Official Name and Position | Angie Grogan (PARTNER/DIRECTOR OF OPERATIONS) |
| Authorized Official Contact | 6083015376 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 454 Waunakee WI 53597-0454 Ph: (608) 886-9023 | 101 E Main St Ste 4 Waunakee WI 53597-1196 Ph: (608) 886-9023 |
| NPI Number | 1639790256 |
|---|---|
| Provider Enumeration Date | 05/05/2020 |
| Last Update Date | 01/30/2025 |
| Certification Date | 01/30/2025 |
| Medicare PECOS PAC ID | 7214374842 |
|---|---|
| Medicare Enrollment ID | O20240319001485 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639790256 | NPI | - | NPPES |
| 4370400 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Scott Alan Ethun |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1447571062 PECOS PAC ID: 3274790530 Enrollment ID: I20190517000936 |
| Provider Name | Danielle J Moore |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1265800817 PECOS PAC ID: 7810336757 Enrollment ID: I20240411003677 |
| Provider Name | Joann Geiger |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1194850982 PECOS PAC ID: 3678910205 Enrollment ID: I20240508002310 |
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