Provider Demographics
NPI:1649027137
Name:VAVAL, GERALYN (SAC-IT)
Entity type:Individual
Prefix:
First Name:GERALYN
Middle Name:
Last Name:VAVAL
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 DONOFRIO DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2053
Mailing Address - Country:US
Mailing Address - Phone:608-820-1395
Mailing Address - Fax:
Practice Address - Street 1:555 DONOFRIO DR STE 201
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2053
Practice Address - Country:US
Practice Address - Phone:608-820-1395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20504130261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder