Healthcare Provider Details

I. General information

NPI: 1497818520
Provider Name (Legal Business Name): JOHN CHARLES IVERSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RIVERVIEW AVE
WAUKESHA WI
53188-3632
US

IV. Provider business mailing address

16960 BURLEIGH PL
BROOKFIELD WI
53005-2753
US

V. Phone/Fax

Practice location:
  • Phone: 262-548-7665
  • Fax: 262-548-7656
Mailing address:
  • Phone: 262-548-7665
  • Fax: 262-548-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number1323
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: