Provider Demographics
NPI:1043402092
Name:MACINTYRE, DAVID J (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:MACINTYRE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 SCHOFIELD AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2300
Mailing Address - Country:US
Mailing Address - Phone:715-298-2846
Mailing Address - Fax:715-298-3146
Practice Address - Street 1:2405 SCHOFIELD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-2300
Practice Address - Country:US
Practice Address - Phone:715-298-2846
Practice Address - Fax:715-298-3146
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional