Provider Demographics
NPI:1902001340
Name:NUTTALL, JOAN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:R
Last Name:NUTTALL
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 1:10701 W NORTH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2314
Mailing Address - Country:US
Mailing Address - Phone:414-771-2450
Mailing Address - Fax:414-771-2451
Practice Address - Street 1:10701 W NORTH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2314
Practice Address - Country:US
Practice Address - Phone:414-771-2450
Practice Address - Fax:414-771-2451
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI742-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist