Basic Information
| Provider Information | |||||||||
| NPI: | 1740245372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THORESEN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 EXCELSIOR DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295201 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 SCIENCE DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082658348 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 162 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39027800 | 05 | WI | MEDICAID |