Provider Demographics
NPI:1164464905
Name:CHRISTIANSON, GARY L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:CHRISTIANSON
Suffix:
Gender:M
Credentials:LCSW
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Mailing Address - Street 1:3267 S 16TH ST
Mailing Address - Street 2:OHIO BUILDING - ROOM 209
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4500
Mailing Address - Country:US
Mailing Address - Phone:414-389-3111
Mailing Address - Fax:414-389-3110
Practice Address - Street 1:3267 S 16TH ST
Practice Address - Street 2:OHIO BUILDING - ROOM 209
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4500
Practice Address - Country:US
Practice Address - Phone:414-389-3111
Practice Address - Fax:414-389-3110
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1762-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39621700Medicaid