Provider Demographics
NPI:1063433951
Name:JULIETTE MARTIN-THOMAS PHD SC
Entity type:Organization
Organization Name:JULIETTE MARTIN-THOMAS PHD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-365-9444
Mailing Address - Street 1:1001 W GLEN OAKS LN STE 105
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3369
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:
Practice Address - Street 1:8901 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1901
Practice Address - Country:US
Practice Address - Phone:414-365-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39023900Medicaid
WI000088151Medicare PIN