Provider Demographics
NPI:1649859943
Name:GAO, FANCHEN (LPCIT)
Entity type:Individual
Prefix:
First Name:FANCHEN
Middle Name:
Last Name:GAO
Suffix:
Gender:M
Credentials:LPCIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 N LYDELL AVE APT 125
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5851
Mailing Address - Country:US
Mailing Address - Phone:414-399-2788
Mailing Address - Fax:
Practice Address - Street 1:1971 WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2125
Practice Address - Country:US
Practice Address - Phone:262-377-6276
Practice Address - Fax:262-377-6289
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19275-130101YA0400X
WI4887-226101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health