Basic Information
| Provider Information | |||||||||
| NPI: | 1013075720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMARCO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2311 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1013075720 | 05 | WI | MEDICAID | 39137100 | 05 | WI | MEDICAID |