Provider Demographics
NPI:1972295376
Name:MCKAY, PAUL MAVERICK (PHD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MAVERICK
Last Name:MCKAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5160 N LYDELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 E SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-4704
Practice Address - Country:US
Practice Address - Phone:414-324-7801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103K00000X, 103TH0004X
261QC1800X, 374K00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner