Provider Demographics
NPI:1073756623
Name:WISTEIN, GERALD (ICS, CSAC, MSW)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:WISTEIN
Suffix:
Gender:M
Credentials:ICS, CSAC, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7538 MID TOWN RD APT 101
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-3454
Mailing Address - Country:US
Mailing Address - Phone:434-270-6015
Mailing Address - Fax:
Practice Address - Street 1:300 FEMRITE DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3716
Practice Address - Country:US
Practice Address - Phone:608-204-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1541-132101YA0400X
WI955-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker