Provider Demographics
NPI:1548479736
Name:GIBCKE, GERALD J (CSAC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:GIBCKE
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 WISCONSIN ST N APT 213
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1063
Mailing Address - Country:US
Mailing Address - Phone:715-386-1399
Mailing Address - Fax:
Practice Address - Street 1:320 21ST ST N
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2228
Practice Address - Country:US
Practice Address - Phone:715-235-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1887132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)