Provider Demographics
NPI:1013185586
Name:GALLITZ, GARY M (LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:GALLITZ
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10137 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1435
Mailing Address - Country:US
Mailing Address - Phone:262-337-0255
Mailing Address - Fax:
Practice Address - Street 1:10500 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5585
Practice Address - Country:US
Practice Address - Phone:262-240-0427
Practice Address - Fax:262-240-0429
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3830-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3830-125OtherLICENSE