Provider Demographics
NPI:1497779102
Name:THEIS, GERALD ALLAN (MSW)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:ALLAN
Last Name:THEIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2116
Mailing Address - Country:US
Mailing Address - Phone:414-871-9111
Mailing Address - Fax:414-871-9121
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:414-871-9121
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI362-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39533800Medicaid
WI084710037Medicare ID - Type Unspecified