Provider Demographics
NPI:1770281461
Name:STEIN, GIDEON JACOB (PMHNP)
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:JACOB
Last Name:STEIN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:SSM HEALTH BEHAVIORAL HEALTH
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:920-926-8343
Mailing Address - Fax:
Practice Address - Street 1:231 N NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2884
Practice Address - Country:US
Practice Address - Phone:920-907-8201
Practice Address - Fax:920-907-8209
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13626-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health