Provider Demographics
NPI:1457865123
Name:WATKINS-GOBBEO, TRACEY MICHELLE (LPC-IT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MICHELLE
Last Name:WATKINS-GOBBEO
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-1518
Mailing Address - Country:US
Mailing Address - Phone:262-334-4340
Mailing Address - Fax:262-334-4341
Practice Address - Street 1:7280 S 13TH ST
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1831
Practice Address - Country:US
Practice Address - Phone:262-334-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3717-226101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health