Provider Demographics
NPI:1104708072
Name:DAVID, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DAVID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 E RANDOLPH CT APT A
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1840
Mailing Address - Country:US
Mailing Address - Phone:414-963-6272
Mailing Address - Fax:414-963-6272
Practice Address - Street 1:1331 E RANDOLPH CT APT A
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1840
Practice Address - Country:US
Practice Address - Phone:414-963-6272
Practice Address - Fax:414-963-6272
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI712621103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool