MEDICARE: JOHN GILANE LCSW, CSAC, ICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2306-132	WI
2	1041C0700X	Clinical Social Worker	6672-123	WI

General Provider Information

NPI Number	:	1720336688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN GILANE LCSW, CSAC, ICS

Provider Business Mailing Address
First Line	:	2683 NORTHWOODS LN
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-9785
Country	:	US
Telephone Number	:	262-844-5758
Fax Number	:

Provider Business Practice Location Address
First Line	:	11512 N PORT WASHINGTON RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-3453
Country	:	US
Telephone Number	:	262-844-5758
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2012
Last Update Date	:	03/01/2020

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