Provider Demographics
NPI:1083170732
Name:GORECKI PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:GORECKI PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GORECKI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-546-7478
Mailing Address - Street 1:19275 W CAPITOL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2734
Mailing Address - Country:US
Mailing Address - Phone:262-546-7478
Mailing Address - Fax:262-373-0362
Practice Address - Street 1:19275 W CAPITOL DR STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2734
Practice Address - Country:US
Practice Address - Phone:262-546-7478
Practice Address - Fax:262-373-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1649361775OtherNPI
WI2810-057OtherCP LICENSE