MEDICARE: MR. GARY ROBERT PROBST LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	577849	WI

General Provider Information

NPI Number	:	1609318567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY ROBERT PROBST LPC

Provider Business Mailing Address
First Line	:	843 BRIDLEWOOD DR
Second Line	:
City	:	HARTFORD
State	:	WI
Zip	:	53027-2799
Country	:	US
Telephone Number	:	262-244-0729
Fax Number	:	866-238-3845

Provider Business Practice Location Address
First Line	:	384 W SUMNER ST
Second Line	:
City	:	HARTFORD
State	:	WI
Zip	:	53027-1421
Country	:	US
Telephone Number	:	262-244-0729
Fax Number	:	866-238-3845

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	11/09/2016

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