Healthcare Provider Details

I. General information

NPI: 1538451075
Provider Name (Legal Business Name): WISCONSIN GERIATRIC PSYCHOLOGICAL SERVICES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3254 S 86TH ST
MILWAUKEE WI
53227-4620
US

IV. Provider business mailing address

3254 S 86TH ST
MILWAUKEE WI
53227-4620
US

V. Phone/Fax

Practice location:
  • Phone: 718-268-6600
  • Fax: 718-268-6065
Mailing address:
  • Phone: 718-268-6600
  • Fax: 718-268-6065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1998-57
License Number StateWI

VIII. Authorized Official

Name: PATRICIA C STANIK
Title or Position: PSYCHOLOGIST
Credential: PH.D
Phone: 414-444-9811