Basic Information
| Provider Information | |||||||||
| NPI: | 1992865760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 AMERICAN AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 AMERICAN AVE | ||||||||
| Address2: | SUITE 501 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | 12279 | WI | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 2231-123 | WI | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39239900 | 05 | WI | MEDICAID |