Provider Demographics
NPI:1659249175
Name:GARD, CARLIE JOANN
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:JOANN
Last Name:GARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4313
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:414-325-7753
Practice Address - Street 1:4811 S 76TH ST STE 305
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:414-325-7741
Practice Address - Fax:414-325-7753
Is Sole Proprietor?:No
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1196-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist