NPIMap

Organization Active NPI

North Shore Psychotherapy Associates IV

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Glendale, WI
National Provider Identifier
1194809574
Registry record updated May 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
Legal business name
NORTH SHORE PSYCHOTHERAPY ASSOCIATES IV
Practice address
5555 N Port Washington Rd Ste 300
Glendale, WI 53217-4928
Phone
(414) 962-6764
Fax
(414) 962-6765
NPI assigned
Oct 24, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 8, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Sheryl Dolezal, PSYDNPI 1497839872
Title
Co Director
Phone
(414) 962-6764

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC0700X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X Primary

Addresses

Primary practice location

5555 N Port Washington Rd Ste 300
Glendale, WI 53217-4928

Mailing address

5555 N Port Washington Rd Ste 300
Glendale, WI 53217-4928
Phone (414) 962-6764

Other identifiers 2

IdentifierTypeStateIssuer
100047128MedicaidWI
K100345509OtherWIMEDICARE

Other names 1

  • NSPA Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090116000521 WI Part B Supplier - Clinic/Group Practice 4688737646 Receives reassigned benefits from 2 practitioners
Practice locations: Glendale, WI
O20161129002490 WI Part B Supplier - Clinic/Group Practice 7911287461 Receives reassigned benefits from 6 practitioners
Practice locations: Milwaukee, WI

National Provider Directory

National Provider Directory

Locations

5800 N Bayshore Dr
Ste A25
Glendale, WI 53217
Phone (414) 962-6764

5555 N Port Washington Rd
Ste 300
Glendale, WI 53217
Phone (414) 962-6764

5800 N Bayshore Dr
#A250
Glendale, WI 53217
Phone (414) 962-6764

5900 N Port Washington Rd
#150
Milwaukee, WI 53217
Phone (414) 962-6764

5800 N Bayshore Dr
Ste A250
Milwaukee, WI 53217
Phone (414) 962-6764

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1683504000000",
    "number": "1194809574",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5555 N PORT WASHINGTON RD STE 300",
            "city": "GLENDALE",
            "state": "WI",
            "postal_code": "532174928",
            "telephone_number": "414-962-6764",
            "fax_number": "414-962-6765"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5555 N PORT WASHINGTON RD STE 300",
            "city": "GLENDALE",
            "state": "WI",
            "postal_code": "532174928",
            "telephone_number": "414-962-6764",
            "fax_number": "414-962-6765"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTH SHORE PSYCHOTHERAPY ASSOCIATES IV",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-24",
        "last_updated": "2023-05-08",
        "certification_date": "2023-05-08",
        "status": "A",
        "authorized_official_last_name": "DOLEZAL",
        "authorized_official_first_name": "SHERYL",
        "authorized_official_title_or_position": "CO DIRECTOR",
        "authorized_official_telephone_number": "414-962-6764",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100047128",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "K100345509",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NSPA",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "NSPA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Glendale, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.