Provider Demographics
NPI:1033276282
Name:MATUSIAK, ITZHAK (PHD)
Entity Type:Individual
Prefix:
First Name:ITZHAK
Middle Name:
Last Name:MATUSIAK
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 1:7161 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3877
Mailing Address - Country:US
Mailing Address - Phone:414-352-7682
Mailing Address - Fax:414-352-7625
Practice Address - Street 1:7161 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-3877
Practice Address - Country:US
Practice Address - Phone:414-352-7682
Practice Address - Fax:414-352-7625
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0650103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39007000Medicaid
WIP90108Medicare UPIN