Provider Demographics
NPI:1336628346
Name:DR MICHELLE L IYAMAH PSYCHODIAGNOSTICS LLC
Entity Type:Organization
Organization Name:DR MICHELLE L IYAMAH PSYCHODIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PASCAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMILEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-432-0919
Mailing Address - Street 1:933 N MAYFAIR RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3432
Mailing Address - Country:US
Mailing Address - Phone:414-551-4773
Mailing Address - Fax:
Practice Address - Street 1:933 N MAYFAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3432
Practice Address - Country:US
Practice Address - Phone:414-551-4773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100004821Medicaid