Healthcare Provider Details

I. General information

NPI: 1194826545
Provider Name (Legal Business Name): RICHARD J. ERTL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 N PROSPECT AVE SUITE 510
MILWAUKEE WI
53202-6319
US

IV. Provider business mailing address

2266 N PROSPECT AVE SUITE 510
MILWAUKEE WI
53202-6319
US

V. Phone/Fax

Practice location:
  • Phone: 414-226-0137
  • Fax: 414-226-0137
Mailing address:
  • Phone: 414-226-0137
  • Fax: 414-226-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1767-057
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1767-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: