Provider Demographics
NPI:1174544746
Name:GERNDT, JAMES K (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:K
Last Name:GERNDT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3463
Mailing Address - Country:US
Mailing Address - Phone:608-237-8000
Mailing Address - Fax:608-237-8005
Practice Address - Street 1:6300 UNIVERSITY AVE
Practice Address - Street 2:SUITE 25
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3463
Practice Address - Country:US
Practice Address - Phone:608-237-8000
Practice Address - Fax:608-237-8005
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1249-057103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39201000Medicaid