Healthcare Provider Details

I. General information

NPI: 1568187987
Provider Name (Legal Business Name): JOHN GRYCH PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N 16TH ST
MILWAUKEE WI
53233-2117
US

IV. Provider business mailing address

604 N 16TH ST
MILWAUKEE WI
53233-2117
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-7460
  • Fax:
Mailing address:
  • Phone: 414-288-7460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1859-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: