NPIMap

Organization Active NPI

Psychology Clinic Inc.

  • Clinic/Center
  • Madison, WI
National Provider Identifier
1336222769
Registry record updated Mar 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
1919 Issued in WI
Legal business name
PSYCHOLOGY CLINIC INC.
Practice address
702 N Blackhawk Ave Ste 212
Madison, WI 53705-3357
Phone
(608) 238-9991
Fax
(608) 238-1929
NPI assigned
Oct 21, 2006
Last updated
Mar 5, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. David Roethe, PH.D.NPI 1548338239
Title
Psychologist/Co-Director
Phone
(608) 280-6486

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 1919 WI Primary

Addresses

Primary practice location

702 N Blackhawk Ave Ste 212
Madison, WI 53705-3357

Mailing address

702 N Blackhawk Ave Ste 212
Madison, WI 53705-3357
Phone (608) 238-9991

Other practice location 1

2985 Triverton Pike Dr Ste 201
Fitchburg, WI 53711-5803
Phone (608) 238-9991

Other practice location 2

1190 Prairie St
Prairie Du Sac, WI 53578-2044
Phone (608) 370-6551

Other practice location 3

137 3rd Ave
Baraboo, WI 53913-2421
Phone (608) 448-2797

Other identifiers 1

IdentifierTypeStateIssuer
42161100MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040421000182 WI Part B Supplier - Clinic/Group Practice 0143216747 Receives reassigned benefits from 15 practitioners
Practice locations: Baraboo, WI; Madison, WI; Prairie Du Sac, WI

National Provider Directory

National Provider Directory

Locations

137 3rd Ave
Baraboo, WI 53913
Phone (608) 448-2797

310 N Midvale Blvd
Madison, WI 53705
Phone (608) 238-9991

310 N Midvale Blvd
Ste 202
Madison, WI 53705
Phone (608) 238-9991

702 N Blackhawk Ave
Ste 212
Madison, WI 53705
Phone (608) 238-9991

Practitioners & affiliated clinicians

Practitioners 49

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 49

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161388800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741132800000",
    "number": "1336222769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 N BLACKHAWK AVE STE 212",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537053357",
            "telephone_number": "608-238-9991",
            "fax_number": "608-238-1929"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "702 N BLACKHAWK AVE STE 212",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537053357",
            "telephone_number": "608-238-9991",
            "fax_number": "608-238-1929"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2985 Triverton Pike Dr Ste 201",
            "address_purpose": "LOCATION",
            "city": "Fitchburg",
            "state": "WI",
            "postal_code": "537115803",
            "country_code": "US",
            "telephone_number": "608-238-9991",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1190 Prairie St",
            "address_purpose": "LOCATION",
            "city": "Prairie Du Sac",
            "state": "WI",
            "postal_code": "535782044",
            "country_code": "US",
            "telephone_number": "608-370-6551",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "137 3rd Ave",
            "address_purpose": "LOCATION",
            "city": "Baraboo",
            "state": "WI",
            "postal_code": "539132421",
            "country_code": "US",
            "telephone_number": "608-448-2797",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PSYCHOLOGY CLINIC INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-21",
        "last_updated": "2025-03-05",
        "certification_date": "2025-03-05",
        "status": "A",
        "authorized_official_last_name": "ROETHE",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "PSYCHOLOGIST/CO-DIRECTOR",
        "authorized_official_telephone_number": "608-280-6486",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "WI",
            "license": "1919",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "42161100",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Madison, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.