Provider Demographics
NPI:1508065582
Name:PULVERMACHER, DOUG RYAN (MS LPC)
Entity Type:Individual
Prefix:MR
First Name:DOUG
Middle Name:RYAN
Last Name:PULVERMACHER
Suffix:
Gender:M
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 N 68TH STREET
Mailing Address - Street 2:#207
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-750-5261
Mailing Address - Fax:
Practice Address - Street 1:3903 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-342-2060
Practice Address - Fax:414-342-3663
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3427125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40952100Medicaid