MEDICARE: JIM MORNINGSTAR PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	473-057	WI

General Provider Information

NPI Number	:	1669687406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIM MORNINGSTAR PH.D.

Provider Business Mailing Address
First Line	:	2728 N PROSPECT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-3768
Country	:	US
Telephone Number	:	414-962-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 W GOOD HOPE RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53209-2250
Country	:	US
Telephone Number	:	414-351-5770
Fax Number	:	414-351-5760

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	07/08/2007

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