Provider Demographics
NPI:1649361775
Name:GORECKI, KIM MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:GORECKI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19275 W CAPITOL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2734
Mailing Address - Country:US
Mailing Address - Phone:262-546-7478
Mailing Address - Fax:262-373-0362
Practice Address - Street 1:19275 W CAPITOL DR STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2734
Practice Address - Country:US
Practice Address - Phone:262-546-7478
Practice Address - Fax:262-373-0362
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2810-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2810-057OtherLP
WI3638125OtherLPC