Provider Demographics
NPI: | 1457597932 |
---|---|
Name: | PIKALEK, GERALDINE REBECCA (MS, LPC) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | GERALDINE |
Middle Name: | REBECCA |
Last Name: | PIKALEK |
Suffix: | |
Gender: | F |
Credentials: | MS, LPC |
Other - Prefix: | MISS |
Other - First Name: | JERI |
Other - Middle Name: | REBECCA |
Other - Last Name: | SWIONTEK |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MS, LPC |
Mailing Address - Street 1: | 1040 S 70TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MILWAUKEE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53214-3174 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 414-476-9675 |
Mailing Address - Fax: | 414-615-0627 |
Practice Address - Street 1: | 1040 S 70TH ST |
Practice Address - Street 2: | |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53214-3174 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-476-9675 |
Practice Address - Fax: | 414-615-0627 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-01-05 |
Last Update Date: | 2011-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
171M00000X | ||
WI | 4501-125 | 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 104100000X | Medicaid |