Provider Demographics
NPI:1629755889
Name:GAEDTKE, MARISSA A (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:A
Last Name:GAEDTKE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:A
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:1501 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5906
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10856-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional