Provider Demographics
NPI:1588684807
Name:BETLEJ, GREGORY (LCSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BETLEJ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:262-641-9126
Practice Address - Street 1:6416 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1104
Practice Address - Country:US
Practice Address - Phone:414-762-5429
Practice Address - Fax:414-762-9727
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1443-125101YP2500X
WI2195-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39298700Medicaid