Basic Information
| Provider Information | |||||||||
| NPI: | 1972756013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BECKER-GIBEAU PSYCHOLOGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Practice Location | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | GIBEAU | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2623772006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2330-057 | WI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 2344-057 | WI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.