Provider Demographics
NPI:1194826545
Name:ERTL, RICHARD J (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:ERTL
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 1:2266 N PROSPECT AVE
Mailing Address - Street 2:SUITE 510
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6319
Mailing Address - Country:US
Mailing Address - Phone:414-226-0137
Mailing Address - Fax:414-226-0137
Practice Address - Street 1:2266 N PROSPECT AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6319
Practice Address - Country:US
Practice Address - Phone:414-226-0137
Practice Address - Fax:414-226-0137
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1767-057103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39101700Medicaid
WIR60582OtherUPIN
WI021400812Medicare UPIN