Healthcare Provider Details

I. General information

NPI: 1093886723
Provider Name (Legal Business Name): DOUGLAS CLYDE BREY LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 WASHINGTON AVE
OSHKOSH WI
54901-5030
US

IV. Provider business mailing address

220 WASHINGTON AVE
OSHKOSH WI
54901-5030
US

V. Phone/Fax

Practice location:
  • Phone: 920-236-4700
  • Fax: 920-236-1157
Mailing address:
  • Phone: 920-236-4700
  • Fax: 920-236-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4871
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301011664
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: