Provider Demographics
NPI:1942335260
Name:TONNACLIFF, MYLES D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYLES
Middle Name:D
Last Name:TONNACLIFF
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:W62N248 WASHINGTON AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2768
Mailing Address - Country:US
Mailing Address - Phone:622-618-2856
Mailing Address - Fax:
Practice Address - Street 1:W62N248 WASHINGTON AVE STE 208
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2768
Practice Address - Country:US
Practice Address - Phone:262-618-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2282-125101YP2500X
WI2163-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2163-057OtherLICENSED PSYCHOLOGIST
WI39154700Medicaid
WI39154700Medicaid