Basic Information
| Provider Information | |||||||||
| NPI: | 1639208440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHEISTER | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1155 N MAYFAIR RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149558900 | ||||||||
| FaxNumber: | 4149556285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 52693 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1639208440 | 05 | WI | MEDICAID |