Provider Demographics
NPI:1104648369
Name:VIBRANT CHILD PSYCHOLOGY SERVICES LLC
Entity type:Organization
Organization Name:VIBRANT CHILD PSYCHOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DELIE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-687-1285
Mailing Address - Street 1:2945 N 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4705
Mailing Address - Country:US
Mailing Address - Phone:414-687-1285
Mailing Address - Fax:414-310-0560
Practice Address - Street 1:10150 W NATIONAL AVE STE 315
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2153
Practice Address - Country:US
Practice Address - Phone:262-668-8870
Practice Address - Fax:414-310-0560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty