Healthcare Provider Details

I. General information

NPI: 1558176511
Provider Name (Legal Business Name): GIBWATER ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 N 56TH ST # WI53208
MILWAUKEE WI
53208-1609
US

IV. Provider business mailing address

2009 N 56TH ST # WI53208
MILWAUKEE WI
53208-1609
US

V. Phone/Fax

Practice location:
  • Phone: 414-931-0000
  • Fax:
Mailing address:
  • Phone: 414-931-1372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ROSS FRESHWATER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 414-931-0000