Provider Demographics
NPI:1487714705
Name:GNAS, JANICE A (MSMBALPCNCCBCC)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:A
Last Name:GNAS
Suffix:
Gender:F
Credentials:MSMBALPCNCCBCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510711
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-0121
Mailing Address - Country:US
Mailing Address - Phone:414-704-2104
Mailing Address - Fax:888-731-8368
Practice Address - Street 1:611 N MAYFAIR RD
Practice Address - Street 2:UPPER LEVEL
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4248
Practice Address - Country:US
Practice Address - Phone:414-704-2104
Practice Address - Fax:888-731-8368
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11514101YA0400X
WI659-125101YP2500X, 101YP2500X
WI228871101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39659600Medicaid