Healthcare Provider Details

I. General information

NPI: 1568578912
Provider Name (Legal Business Name): GALE ZICCARELLI MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 63RD ST
KENOSHA WI
53143-4454
US

IV. Provider business mailing address

6233 39TH AVE
KENOSHA WI
53142-7015
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-2406
  • Fax: 262-652-2408
Mailing address:
  • Phone: 262-654-1004
  • Fax: 262-654-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7129-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: