Provider Demographics
NPI:1518907633
Name:MARTIN THOMAS, JULIETTE (PHD)
Entity Type:Individual
Prefix:
First Name:JULIETTE
Middle Name:
Last Name:MARTIN THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W GLEN OAKS LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3365
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-2937
Practice Address - Street 1:8901 NORTH 76TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223
Practice Address - Country:US
Practice Address - Phone:414-365-9444
Practice Address - Fax:262-241-0773
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI906057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39023900Medicaid
WI39023900Medicaid
WI000088151Medicare PIN