Provider Demographics
NPI:1104981653
Name:HEATH, GARY D (LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:HEATH
Suffix:
Gender:M
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 E ROSSMAN ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-1237
Mailing Address - Country:US
Mailing Address - Phone:262-673-3522
Mailing Address - Fax:
Practice Address - Street 1:12970 W BLUEMOUND RD
Practice Address - Street 2:SUITE 105
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2607
Practice Address - Country:US
Practice Address - Phone:262-787-2904
Practice Address - Fax:262-787-2909
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2027-1231041C0700X
WI339-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40955300Medicaid