Provider Demographics
NPI:1467923474
Name:BRIAN M. FIDLIN PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:BRIAN M. FIDLIN PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FIDLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-837-6391
Mailing Address - Street 1:PO BOX 171009
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8092
Mailing Address - Country:US
Mailing Address - Phone:414-837-6391
Mailing Address - Fax:
Practice Address - Street 1:14135 N CEDARBURG RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-1416
Practice Address - Country:US
Practice Address - Phone:262-377-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)