Provider Demographics
NPI:1073613105
Name:FOKER, GREGORY ROBERT (PHD)
Entity Type:Individual
Prefix:PROF
First Name:GREGORY
Middle Name:ROBERT
Last Name:FOKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:ROBERT
Other - Last Name:FOKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1525 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2932
Mailing Address - Country:US
Mailing Address - Phone:262-377-8142
Mailing Address - Fax:
Practice Address - Street 1:5225 N IRONWOOD LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4909
Practice Address - Country:US
Practice Address - Phone:414-962-9156
Practice Address - Fax:414-962-4356
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12664101YA0400X
WI654-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY39709400Medicaid