Healthcare Provider Details

I. General information

NPI: 1245425354
Provider Name (Legal Business Name): NEUROBEHAVIORAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 N PORT WASHINGTON RD
GLENDALE WI
53217-4308
US

IV. Provider business mailing address

419 W RIVER FRONT DR
GLENDALE WI
53217-4460
US

V. Phone/Fax

Practice location:
  • Phone: 414-803-0231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2478
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2478
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2478
License Number StateWI

VIII. Authorized Official

Name: KIMBERLY M RENNIE
Title or Position: OWNER
Credential: PHD
Phone: 414-803-0231