Healthcare Provider Details

I. General information

NPI: 1023662459
Provider Name (Legal Business Name): DOMENICK TIRABASSI IV PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 W CENTER ST STE 203
MILWAUKEE WI
53222-4548
US

IV. Provider business mailing address

9205 W CENTER ST STE 203
MILWAUKEE WI
53222-4548
US

V. Phone/Fax

Practice location:
  • Phone: 414-377-4787
  • Fax: 866-643-0083
Mailing address:
  • Phone: 414-377-4787
  • Fax: 866-643-0083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5089-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: