Healthcare Provider Details

I. General information

NPI: 1760992788
Provider Name (Legal Business Name): MILWAUKEE PSYCHOTHERAPY COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W HAMPTON AVE STE 212
MILWAUKEE WI
53225-4960
US

IV. Provider business mailing address

9120 W HAMPTON AVE STE 212
MILWAUKEE WI
53225-4960
US

V. Phone/Fax

Practice location:
  • Phone: 414-367-9413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2973
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number303957
License Number StateWI

VIII. Authorized Official

Name: DR. DAVID BRIAN SMOTHERS
Title or Position: OWNER
Credential:
Phone: 414-367-9413