Provider Demographics
NPI:1134347016
Name:GILBERTSON, STEPHEN ANDREW (LIC PSYCHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:GILBERTSON
Suffix:
Gender:M
Credentials:LIC PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3465
Mailing Address - Country:US
Mailing Address - Phone:262-240-9620
Mailing Address - Fax:
Practice Address - Street 1:11501 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 218
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3465
Practice Address - Country:US
Practice Address - Phone:262-240-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical