MEDICARE: DR. DOUGLAS MARK HARDY PHD

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	1815057	WI
2	103T00000X	Psychologist	1815-057	WI

General Provider Information

NPI Number	:	1760584973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS MARK HARDY PHD

Provider Business Mailing Address
First Line	:	9455 W WATERTOWN PLANK RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-3559
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9455 W WATERTOWN PLANK RD
Second Line	:	MILWAUKEE COUNTY BEHAVIORAL HEALTH DIVISION
City	:	MILWAUKEE
State	:	WI
Zip	:	53226-3559
Country	:	US
Telephone Number	:	414-257-6995
Fax Number	:

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	09/30/2008

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