Healthcare Provider Details

I. General information

NPI: 1518907633
Provider Name (Legal Business Name): JULIETTE MARTIN THOMAS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 NORTH 76TH STREET
MILWAUKEE WI
53223
US

IV. Provider business mailing address

1001 W GLEN OAKS LN SUITE 105
MEQUON WI
53092-3365
US

V. Phone/Fax

Practice location:
  • Phone: 414-365-9444
  • Fax: 262-241-0773
Mailing address:
  • Phone: 414-365-3210
  • Fax: 414-365-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number906057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: