Healthcare Provider Details

I. General information

NPI: 1194451047
Provider Name (Legal Business Name): SYDNEY ELIZABETH PARK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

2501 N 55TH ST
MILWAUKEE WI
53210-2746
US

V. Phone/Fax

Practice location:
  • Phone: 262-366-4318
  • Fax:
Mailing address:
  • Phone: 262-366-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number5160-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: