Healthcare Provider Details

I. General information

NPI: 1528486263
Provider Name (Legal Business Name): ALAN SUMWALT PSYCHOTHERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 PARK AVE PEWAUKEE, WI
PEWAUKEE WI
53072-3410
US

IV. Provider business mailing address

146 PARK AVE PEWAUKEE, WI
PEWAUKEE WI
53072-3410
US

V. Phone/Fax

Practice location:
  • Phone: 414-588-6452
  • Fax: 262-691-3005
Mailing address:
  • Phone: 414-588-6452
  • Fax: 262-691-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number346-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number346-123
License Number StateWI

VIII. Authorized Official

Name: ALAN W SUMWALT
Title or Position: DIRECTOR
Credential: MSW, LCSW, LMFT
Phone: 414-588-6452