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General NPI Number Information
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NPI Number | 1073756623
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Entity Type | Individual
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Provider Name | GERALD WISTEIN ICS, CSAC, MSW
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Gender | Male
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 06/08/2016
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Provider Practice Location Address
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Address Line | 300 FEMRITE DR
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City | MONONA
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State | WI
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Zip | 53716-3716
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Country | US
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Telephone | 608-204-8491
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Fax |
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Provider Business Mailing Address
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Address Line | 7538 MID TOWN RD APT 101
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City | MADISON
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State | WI
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Zip | 53719-3454
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Country | US
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Telephone | 434-270-6015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1541-132
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 955-120
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License Number State | WI
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