Provider Demographics
NPI:1386886976
Name:BERTNICK-GILLIGAN, COURTNEY L (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:L
Last Name:BERTNICK-GILLIGAN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 REMPE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1264
Mailing Address - Country:US
Mailing Address - Phone:414-659-0509
Mailing Address - Fax:
Practice Address - Street 1:5757 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-4303
Practice Address - Country:US
Practice Address - Phone:414-431-6400
Practice Address - Fax:414-431-6401
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7831-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
K400092206Medicare PIN