Healthcare Provider Details

I. General information

NPI: 1609092378
Provider Name (Legal Business Name): GARY L KEZELE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 W TOWNE SQUARE RD
MEQUON WI
53092-5017
US

IV. Provider business mailing address

2247 MIRAMONTE CIR W UNIT B
PALM SPRINGS CA
92264-5781
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-5099
  • Fax: 262-241-5054
Mailing address:
  • Phone: 760-992-3921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1214-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: