Provider Demographics
NPI:1598743239
Name:SHUCK, THERESA MARIE (MS,MA,LCGC,LPC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:SHUCK
Suffix:
Gender:F
Credentials:MS,MA,LCGC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 ANDY JOHN CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6371
Mailing Address - Country:US
Mailing Address - Phone:920-606-0130
Mailing Address - Fax:
Practice Address - Street 1:15300 WATERTOWN PLANK RD #106
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-7503
Practice Address - Country:US
Practice Address - Phone:414-807-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI170300000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No170300000XOther Service ProvidersGenetic Counselor, MS