Healthcare Provider Details

I. General information

NPI: 1306488440
Provider Name (Legal Business Name): STEPHEN JOSEPH OHLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 W HIGHLAND BLVD
MILWAUKEE WI
53208-3252
US

IV. Provider business mailing address

719 E OKLAHOMA AVE
MILWAUKEE WI
53207-2404
US

V. Phone/Fax

Practice location:
  • Phone: 414-342-4560
  • Fax: 414-345-3534
Mailing address:
  • Phone: 414-750-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number712-228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: