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General NPI Number Information
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NPI Number | 1932312212
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Entity Type | Organization
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Legal Business Name | PSYCHIATRIC & PSYCHOTHERAPY CLINIC L I NEWMAN MD SC GEN PTR
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 3601 30TH AVE STE 102
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City | KENOSHA
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State | WI
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Zip | 53144-1642
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Country | US
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Telephone | 262-654-0487
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Fax | 262-654-2434
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Provider Business Mailing Address
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Address Line | 3601 30TH AVE STE 102
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City | KENOSHA
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State | WI
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Zip | 53144-1642
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Country | US
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Telephone | 262-654-0487
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Fax | 262-654-2434
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Authorized Official
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Title or Position | OWNER
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Name | PAUL M DEFAZIO
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Credential |
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Telephone | 262-654-0487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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