Provider Demographics
NPI:1295847002
Name:ZYLSTRA, MARC W (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:W
Last Name:ZYLSTRA
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 1:2525 N MAYFAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1403
Mailing Address - Country:US
Mailing Address - Phone:414-476-8183
Mailing Address - Fax:414-476-8465
Practice Address - Street 1:2525 N MAYFAIR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1403
Practice Address - Country:US
Practice Address - Phone:414-476-8183
Practice Address - Fax:414-476-8465
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1817-057103TC0700X, 103T00000X, 103TP2701X
WI43715103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21280000Medicaid
WI39640900Medicaid
WI21280000Medicaid