Healthcare Provider Details

I. General information

NPI: 1144438672
Provider Name (Legal Business Name): SUSAN DVORAK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W HAMPTON AVE SUITE 90
MILWAUKEE WI
53225-4960
US

IV. Provider business mailing address

133 N 85TH ST
WAUWATOSA WI
53226-4601
US

V. Phone/Fax

Practice location:
  • Phone: 414-466-9777
  • Fax: 414-358-5590
Mailing address:
  • Phone: 414-259-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1423-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: