Healthcare Provider Details

I. General information

NPI: 1497592562
Provider Name (Legal Business Name): DOMINIC DAVID HERMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

IV. Provider business mailing address

3059 N WEIL ST UNIT 110
MILWAUKEE WI
53212-2281
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3835
  • Fax:
Mailing address:
  • Phone: 414-394-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: