MEDICARE: A MOMENT OF RETREAT, LLC

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

General Provider Information

NPI Number	:	1871354340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A MOMENT OF RETREAT, LLC

Provider Business Mailing Address
First Line	:	950 W RIVERVIEW DR
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-4534
Country	:	US
Telephone Number	:	414-617-3704
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 W RIVERVIEW DR
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209-4534
Country	:	US
Telephone Number	:	414-617-3704
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	HEATHER LEE SCHMIDT
Credential	:
Telephone Number	:	414-491-0516

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2024

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Directions to “A MOMENT OF RETREAT, LLC ” Practice Location

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