Provider Demographics
NPI:1578811980
Name:GOOSEBERRY, ORLESIA GAY (CSAC AND SOCIAL WORK)
Entity Type:Individual
Prefix:MRS
First Name:ORLESIA
Middle Name:GAY
Last Name:GOOSEBERRY
Suffix:
Gender:F
Credentials:CSAC AND SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7726 W LISBON AVE
Mailing Address - Street 2:APT # 2
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3945
Mailing Address - Country:US
Mailing Address - Phone:414-617-3684
Mailing Address - Fax:
Practice Address - Street 1:1501 ALBERT ST
Practice Address - Street 2:NORTH UNIT UPPER
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-2713
Practice Address - Country:US
Practice Address - Phone:262-638-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10901-120103K00000X
WI15709-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst