Provider Demographics
NPI:1336445279
Name:GEBHARDT, DAVID ALFRED (SAC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALFRED
Last Name:GEBHARDT
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E JOHNSON ST
Mailing Address - Street 2:2
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1525
Mailing Address - Country:US
Mailing Address - Phone:608-214-8870
Mailing Address - Fax:
Practice Address - Street 1:5212 COUNTY HIGHWAY M
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575
Practice Address - Country:US
Practice Address - Phone:608-835-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15615131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)