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: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1442 S 92ND ST
WEST ALLIS WI
53214-4235
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 414-731-7452
  • Fax: 414-310-8533
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: 414-731-7452