Healthcare Provider Details

I. General information

NPI: 1609943364
Provider Name (Legal Business Name): ANN M GAYLORD LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 RIVERSIDE DR
GREEN BAY WI
54301-2316
US

IV. Provider business mailing address

1825 RIVERSIDE DR
GREEN BAY WI
54301-2316
US

V. Phone/Fax

Practice location:
  • Phone: 920-272-8234
  • Fax: 920-437-4067
Mailing address:
  • Phone: 920-272-8234
  • Fax: 920-364-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number482-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: