Provider Demographics
NPI:1245393388
Name:CHUBBUCK, JUDSON (LPC)
Entity Type:Individual
Prefix:
First Name:JUDSON
Middle Name:
Last Name:CHUBBUCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4928 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3052
Mailing Address - Country:US
Mailing Address - Phone:414-774-1052
Mailing Address - Fax:
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3233125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40963300Medicaid