Provider Demographics
NPI:1649866096
Name:NUNEZ, MIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MIA
Middle Name:
Last Name:NUNEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 ORCHARD CIR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3497
Mailing Address - Country:US
Mailing Address - Phone:262-269-5311
Mailing Address - Fax:
Practice Address - Street 1:1291 ORCHARD CIR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3497
Practice Address - Country:US
Practice Address - Phone:262-269-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI375657103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical