Provider Demographics
NPI:1194809574
Name:NORTH SHORE PSYCHOTHERAPY ASSOCIATES IV
Entity type:Organization
Organization Name:NORTH SHORE PSYCHOTHERAPY ASSOCIATES IV
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLEZAL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-962-6764
Mailing Address - Street 1:5555 N PORT WASHINGTON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4928
Mailing Address - Country:US
Mailing Address - Phone:414-962-6764
Mailing Address - Fax:414-962-6765
Practice Address - Street 1:5555 N PORT WASHINGTON RD STE 300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4928
Practice Address - Country:US
Practice Address - Phone:414-962-6764
Practice Address - Fax:414-962-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100047128Medicaid
WIK100345509OtherMEDICARE
WIK100345509OtherMEDICARE