Provider Demographics
NPI:1609163732
Name:SKALLERUP, JUDITH CB (LCPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:CB
Last Name:SKALLERUP
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JUDE
Other - Middle Name:
Other - Last Name:SKALLERUP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSOTS, CCFC, LCPC
Mailing Address - Street 1:715 E GOLF RD STE 201B
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4500
Mailing Address - Country:US
Mailing Address - Phone:630-464-7128
Mailing Address - Fax:630-682-1168
Practice Address - Street 1:715 E GOLF RD STE 201B
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4500
Practice Address - Country:US
Practice Address - Phone:630-464-7128
Practice Address - Fax:630-682-1168
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-10
Last Update Date:2011-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-0004615101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor