Provider Demographics
NPI:1144417304
Name:M D THERAPY, LLC
Entity Type:Organization
Organization Name:M D THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:ED PSYCHOLOGY
Authorized Official - Phone:414-466-3204
Mailing Address - Street 1:6815 W CAPITOL DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2070
Mailing Address - Country:US
Mailing Address - Phone:414-466-3204
Mailing Address - Fax:414-466-3206
Practice Address - Street 1:6815 W CAPITOL DR
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2070
Practice Address - Country:US
Practice Address - Phone:414-466-3204
Practice Address - Fax:414-466-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIHFS 61.91251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42217600Medicaid