Provider Demographics
NPI:1134650302
Name:GISSIBL, MICHAEL RICHARD (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:GISSIBL
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 N GRANDVIEW BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1686
Mailing Address - Country:US
Mailing Address - Phone:414-841-9165
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-313-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)