Provider Demographics
NPI:1609092378
Name:KEZELE, GARY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:KEZELE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2247 MIRAMONTE CIR W
Mailing Address - Street 2:UNIT B
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-5781
Mailing Address - Country:US
Mailing Address - Phone:760-992-3921
Mailing Address - Fax:
Practice Address - Street 1:1317 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5017
Practice Address - Country:US
Practice Address - Phone:262-241-5099
Practice Address - Fax:262-241-5054
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1214-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist