Healthcare Provider Details

I. General information

NPI: 1619039021
Provider Name (Legal Business Name): CHARLOTTE GLADBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 AIRPORT ROAD
WAUKESHA WI
53188
US

IV. Provider business mailing address

W384 N6087 NOKOMA DR
OCONOMOWOC WI
53066
US

V. Phone/Fax

Practice location:
  • Phone: 262-896-8103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number76603-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: