Provider Demographics
NPI:1396808226
Name:MILLICHAP, MARTIN GORDON (MA)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:GORDON
Last Name:MILLICHAP
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-548-7688
Mailing Address - Fax:262-548-7656
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-548-7688
Practice Address - Fax:262-548-7656
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2351-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39197000Medicaid