Healthcare Provider Details

I. General information

NPI: 1851629448
Provider Name (Legal Business Name): TISA A AYUSO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 W CONNELL AVE
MILWAUKEE WI
53226-3067
US

IV. Provider business mailing address

5 PERRYRIDGE RD
GREENWICH CT
06830-4697
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2932
  • Fax:
Mailing address:
  • Phone: 203-863-3944
  • Fax: 203-863-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number048692
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number73136
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2706-321
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: