Provider Demographics
NPI:1497818520
Name:IVERSON, JOHN CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:IVERSON
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 1:16960 BURLEIGH PL
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2753
Mailing Address - Country:US
Mailing Address - Phone:262-548-7665
Mailing Address - Fax:262-548-7656
Practice Address - Street 1:500 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3632
Practice Address - Country:US
Practice Address - Phone:262-548-7665
Practice Address - Fax:262-548-7656
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1323103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities