Provider Demographics
NPI:1063532380
Name:HEALTHCARE PSYCHOLOGY CONSULTANTS LLC
Entity type:Organization
Organization Name:HEALTHCARE PSYCHOLOGY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:JORN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-431-4322
Mailing Address - Street 1:1110 N OLD WORLD 3RD ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1121
Mailing Address - Country:US
Mailing Address - Phone:414-431-4322
Mailing Address - Fax:414-431-4323
Practice Address - Street 1:4447 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-431-4322
Practice Address - Fax:414-431-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1912103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39113800Medicaid
WI39113800Medicaid
000001208Medicare ID - Type Unspecified