Provider Demographics
NPI:1134228802
Name:WAKELY, DAVID J (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WAKELY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2907
Mailing Address - Country:US
Mailing Address - Phone:608-754-6000
Mailing Address - Fax:608-755-7892
Practice Address - Street 1:557 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548
Practice Address - Country:US
Practice Address - Phone:608-754-6000
Practice Address - Fax:608-755-7892
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002790103TC0700X
WI2711-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134228802Medicaid
WIP00684638CD3624OtherRR MEDICARE
WI541760589OtherWI MEDICARE
WIWAKELDAVOtherMERCYCARE INSURANCE
WIWAKELDAVOtherMERCYCARE INSURANCE