Healthcare Provider Details

I. General information

NPI: 1467703223
Provider Name (Legal Business Name): JONATHAN T GRAPENGIESER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHAN T GRAPENGIESER PSYD

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 S 70TH ST SUITE S507
WEST ALLIS WI
53214-3151
US

IV. Provider business mailing address

1126 S 70TH ST SUITE S507
WEST ALLIS WI
53214-3151
US

V. Phone/Fax

Practice location:
  • Phone: 414-475-2788
  • Fax: 414-476-8695
Mailing address:
  • Phone: 414-475-2788
  • Fax: 414-476-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3170-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: