Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | 3628-57 | WI |
N | 103TC0700X | Clinical Psychologist | 3628-57 | WI |
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 3628-57 | WI |
NPI | 1083188122 |
---|---|
Provider Name | Angela M Orvis |
First Address | Oconomowoc, WI 53066-4599 |
Second Address | Brown Deer, WI 53223-1475 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2019 |
Last Update Date | 11/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3628-57 | STATE LICENSE (01) | WI |