Healthcare Provider Details

I. General information

NPI: 1932312212
Provider Name (Legal Business Name): PSYCHIATRIC & PSYCHOTHERAPY CLINIC L I NEWMAN MD SC GEN PTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 30TH AVE STE 102
KENOSHA WI
53144-1642
US

IV. Provider business mailing address

3601 30TH AVE STE 102
KENOSHA WI
53144-1642
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-0487
  • Fax: 262-654-2434
Mailing address:
  • Phone: 262-654-0487
  • Fax: 262-654-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: PAUL M DEFAZIO
Title or Position: OWNER
Credential:
Phone: 262-654-0487