Basic Information
| Provider Information | |||||||||
| NPI: | 1801954920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONTKOVSKY | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175 N11163 STONEWOOD DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Practice Location | |||||||||
| Address1: | W175N11163 STONEWOOD DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530226502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3446-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 723 | NE | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 42692 | MS | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 7285 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0108112 | 05 | OH | MEDICAID |