Basic Information
| Provider Information | |||||||||
| NPI: | 1700222338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEGGE | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | GERALYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEEZEN | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | GERALYN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5555 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532174929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 4149677965 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532174929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627891191 | ||||||||
| FaxNumber: | 4149677965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2013 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000-088745 | 01 | WI | GROUP MEDICARE (P-TAN) MILWAUKEE COUNTY | OTHER | 42170300 | 05 | WI | MEDICAID |