MEDICARE: EARL E. BRACY PSYD

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	103T00000X	Psychologist	2295-057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720269186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL E. BRACY PSYD

Provider Business Mailing Address
First Line	:	5225 N IRONWOOD RD
Second Line	:	SUITE 214
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-963-1115
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 N IRONWOOD RD
Second Line	:	SUITE 214
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-963-1115
Fax Number	:

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

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	11/14/2007

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Directions to “ EARL E. BRACY PSYD” Practice Location

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