Healthcare Provider Details

I. General information

NPI: 1598371734
Provider Name (Legal Business Name): CRISTINA MARIE SOTO SULLIVAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRISTINA SOTO SULLIVAN PHD

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 E WEBSTER PL STE 203
MILWAUKEE WI
53211-4257
US

IV. Provider business mailing address

2524 E WEBSTER PL STE 203
MILWAUKEE WI
53211-4257
US

V. Phone/Fax

Practice location:
  • Phone: 414-964-9200
  • Fax:
Mailing address:
  • Phone: 414-964-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3846
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: