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General NPI Number Information
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NPI Number | 1235666017
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Entity Type | Organization
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Legal Business Name | MYLES TONNACLIFF PH.D, LLC
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | W62N248 WASHINGTON AVE SUITE 208
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City | CEDARBURG
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State | WI
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Zip | 53012-2768
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Country | US
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Telephone | 262-618-2856
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Fax |
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Provider Business Mailing Address
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Address Line | W62N248 WASHINGTON AVE SUITE 208
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City | CEDARBURG
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State | WI
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Zip | 53012-2768
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Country | US
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Telephone | 414-617-2663
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Fax |
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Authorized Official
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Title or Position | LICESED PSYCHOLOGIST- OWNER
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Name | MYLES D TONNACLIFF
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Credential | LP
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Telephone | 262-618-2856
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 2163-57
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License Number State | WI
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