Provider Demographics
NPI:1023062528
Name:BRETHAUER, RUSSELL WIESTON (PSYD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WIESTON
Last Name:BRETHAUER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 PILGRIM PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2063
Mailing Address - Country:US
Mailing Address - Phone:262-785-5557
Mailing Address - Fax:262-785-5586
Practice Address - Street 1:700 PILGRIM PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2063
Practice Address - Country:US
Practice Address - Phone:262-785-5557
Practice Address - Fax:262-785-5586
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI983103TC0700X
WI185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39027200Medicaid