Provider Demographics
NPI:1902011257
Name:WISCONSIN SCHOOL OF PROFESSIONAL PSYCHOLOGY
Entity Type:Organization
Organization Name:WISCONSIN SCHOOL OF PROFESSIONAL PSYCHOLOGY
Other - Org Name:WSPP PSYCHOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL TRAINING
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DVORAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-466-9777
Mailing Address - Street 1:9120 W HAMPTON AVE
Mailing Address - Street 2:SUITE 90
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4960
Mailing Address - Country:US
Mailing Address - Phone:414-466-9777
Mailing Address - Fax:414-358-5590
Practice Address - Street 1:9120 W HAMPTON AVE
Practice Address - Street 2:SUITE 90
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-4960
Practice Address - Country:US
Practice Address - Phone:414-466-9777
Practice Address - Fax:414-358-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2001103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42182700Medicaid
WI84509Medicare ID - Type Unspecified