Provider Demographics
NPI:1275702532
Name:GULLICKSON, BETH (LMFT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5534 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1202
Mailing Address - Country:US
Mailing Address - Phone:608-274-0355
Mailing Address - Fax:608-274-5546
Practice Address - Street 1:5534 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1202
Practice Address - Country:US
Practice Address - Phone:608-274-0355
Practice Address - Fax:608-274-5546
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI749-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43722600Medicaid