Provider Demographics
NPI:1235294612
Name:GARBACIAK, JUSTINE MARIE (MS)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARIE
Last Name:GARBACIAK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:MARIE
Other - Last Name:THYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3454 ELMTREE RD
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54313-8339
Mailing Address - Country:US
Mailing Address - Phone:920-639-1032
Mailing Address - Fax:
Practice Address - Street 1:301 N BROADWAY STE 110
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2571
Practice Address - Country:US
Practice Address - Phone:920-370-7167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3839101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43710000Medicaid