Healthcare Provider Details

I. General information

NPI: 1972012144
Provider Name (Legal Business Name): YIXING SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N JEFFERSON ST STE 408
MILWAUKEE WI
53202-3875
US

IV. Provider business mailing address

N62W14355 ROLLING RIDGE DR
MENOMONEE FALLS WI
53051-5863
US

V. Phone/Fax

Practice location:
  • Phone: 414-368-0257
  • Fax:
Mailing address:
  • Phone: 414-368-0257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number552857
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: