Provider Demographics
NPI:1952991390
Name:GERDES, ALYSON
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:GERDES
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 1:1143 WARWICK WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1143 WARWICK WAY UNIT A1143
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5661
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2657-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical