MEDICARE: DR. MARY F WYMAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2566-57	WI

General Provider Information

NPI Number	:	1154302255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY F WYMAN PH.D.

Provider Business Mailing Address
First Line	:	1612 N 53RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-2231
Country	:	US
Telephone Number	:	414-755-1779
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 N 53RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-2231
Country	:	US
Telephone Number	:	414-755-1779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	07/08/2007

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