Healthcare Provider Details

I. General information

NPI: 1326473240
Provider Name (Legal Business Name): PATRICK J STUMBRAS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 08/27/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 MONROE RD
DE PERE WI
54115-8399
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3744-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number357-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: