Provider Demographics
NPI:1700081221
Name:ROHERTY, GERALD MATTHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MATTHEW
Last Name:ROHERTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-2515
Mailing Address - Country:US
Mailing Address - Phone:262-306-7189
Mailing Address - Fax:
Practice Address - Street 1:1784 BARTON AVE
Practice Address - Street 2:SUITE NUMBER 16
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-5474
Practice Address - Country:US
Practice Address - Phone:262-334-1322
Practice Address - Fax:262-334-1325
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2435057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist