Provider Demographics
NPI:1124563143
Name:GAMBLE, TYREE (MS, NCC)
Entity Type:Individual
Prefix:
First Name:TYREE
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:MS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 BEE LN
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1903
Mailing Address - Country:US
Mailing Address - Phone:608-921-4289
Mailing Address - Fax:
Practice Address - Street 1:400 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6200
Practice Address - Country:US
Practice Address - Phone:608-368-8087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2911-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional