Organization
PSYCHIATRIC & PSYCHOTHERAPY CLINIC L I NEWMAN MD SC GEN PTR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PAUL M DEFAZIO (OWNER)
(262) 654-0487
Entity
Organization
Contact information
Practice address
3601 30TH AVE STE 102, KENOSHA, WI 53144-1642
(262) 654-0487
(262) 654-2434
Mailing address
3601 30TH AVE STE 102, KENOSHA, WI 53144-1642
(262) 654-0487
(262) 654-2434
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
103TA0400X
Addiction (Substance Use Disorder) Psychologist
—
—
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42124700
—
WI
Enumeration date
05/07/2007
Last updated
08/11/2011
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