=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285353367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GILLIAN GRACORVITZ APRN, PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2022
-----------------------------------------------------
Last Update Date | 04/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 642 BRAKKE DR STE 105
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-7904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-402-4562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 DURANGO DR
-----------------------------------------------------
City | ROBERTS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54023-8536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-690-9167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 18273-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 2490493
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------