Healthcare Provider Details

I. General information

NPI: 1912702804
Provider Name (Legal Business Name): ANDREA SUSAN GAGE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W VLIET ST
MILWAUKEE WI
53205-2117
US

IV. Provider business mailing address

4507 N NEWHALL ST
SHOREWOOD WI
53211-1528
US

V. Phone/Fax

Practice location:
  • Phone: 414-257-7222
  • Fax:
Mailing address:
  • Phone: 612-619-0588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11041-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: