Provider Demographics
NPI:1407170814
Name:MATYSIK, GREGORY JOHN (LPC, CSAC, PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:MATYSIK
Suffix:
Gender:M
Credentials:LPC, CSAC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FEMRITE DR
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3716
Mailing Address - Country:US
Mailing Address - Phone:608-222-7311
Mailing Address - Fax:608-222-0453
Practice Address - Street 1:300 FEMRITE DR
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3716
Practice Address - Country:US
Practice Address - Phone:608-222-7311
Practice Address - Fax:608-222-0453
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3847 125320800000X
WI15307 132324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness