Russell Wieston Brethauer, PSYD.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

983 Issued in WI

Practice address

700 Pilgrim Pkwy
Suite 201
Elm Grove, WI 53122-2063

Phone

(262) 785-5557

Fax

(262) 785-5586

NPI assigned

May 19, 2006

Sex

Male

Sole proprietor

Yes

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Oct 18, 2007.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1192665600000",
    "number": "1023062528",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 PILGRIM PKWY",
            "address_2": "SUITE 201",
            "city": "ELM GROVE",
            "state": "WI",
            "postal_code": "531222063",
            "telephone_number": "262-785-5557",
            "fax_number": "262-785-5586"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 PILGRIM PKWY",
            "address_2": "SUITE 201",
            "city": "ELM GROVE",
            "state": "WI",
            "postal_code": "531222063",
            "telephone_number": "262-785-5557",
            "fax_number": "262-785-5586"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRETHAUER",
        "first_name": "RUSSELL",
        "middle_name": "WIESTON",
        "credential": "PSYD.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-05-19",
        "last_updated": "2007-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "WI",
            "license": "983",
            "primary": true
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "WI",
            "license": "185",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39027200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Michael A Bonis, P.T.
• Lynette Boshoff, D.C.
• Cory Robert Bowers, PHARMD
• Elissa Box, LPC
• Kimberly Brandhagen, APSW, SAC-IT
• Bright Day Wellness, LLC
• James Joseph Brinks, HIS
• Everest Cameron Brooks, LCSW
• Karin Lynn Buckholdt, PT
• Rene Ann Burgoyne, MS, ATRL-BC

• All providers in Elm Grove, WI
• Clinical Psychologist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.