Provider Demographics
NPI:1497840615
Name:GAZIANO, MICHAEL L (MSW LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:GAZIANO
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449
Mailing Address - Country:US
Mailing Address - Phone:715-384-7579
Mailing Address - Fax:715-384-8131
Practice Address - Street 1:252 S CENTRAL AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449
Practice Address - Country:US
Practice Address - Phone:715-384-7579
Practice Address - Fax:715-384-8131
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6991-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43561500Medicaid
WI2669OtherMENTAL HEALTH-OUTPATIENT