Provider Demographics
NPI:1093707044
Name:PAHLAVAN, JODY ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:ANN
Last Name:PAHLAVAN
Suffix:
Gender:F
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:N48W16080 LONE OAK LN
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7528
Mailing Address - Country:US
Mailing Address - Phone:262-879-0022
Mailing Address - Fax:
Practice Address - Street 1:11101 W LINCOLN AVE
Practice Address - Street 2:ROGERS MEMORIAL HOSPITAL
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1133
Practice Address - Country:US
Practice Address - Phone:414-327-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1694-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39229700Medicaid