Provider Demographics
NPI:1750803557
Name:GILBERT, KATRINA AISHA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:AISHA
Last Name:GILBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 WORLD DAIRY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-3807
Mailing Address - Country:US
Mailing Address - Phone:608-242-0220
Mailing Address - Fax:608-242-1166
Practice Address - Street 1:5109 WORLD DAIRY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:608-242-1166
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17206-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$Medicaid