Provider Demographics
NPI:1477876308
Name:BANNASCH, GLORIA JEAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:JEAN
Last Name:BANNASCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:GLORIA
Other - Middle Name:JEAN
Other - Last Name:BANNASCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED,LPC, NCC
Mailing Address - Street 1:711 N LYNNDALE DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3078
Mailing Address - Country:US
Mailing Address - Phone:920-217-7861
Mailing Address - Fax:920-560-6618
Practice Address - Street 1:711 N LYNNDALE DR STE 1A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3078
Practice Address - Country:US
Practice Address - Phone:920-217-7861
Practice Address - Fax:920-560-6618
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-06
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4281-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00613383Medicaid