Provider Demographics
NPI:1659598746
Name:WIEBUSCH, CHRISTOPHER PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:PAUL
Last Name:WIEBUSCH
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:N27W23953 PAUL RD
Mailing Address - Street 2:STE. 206
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6242
Mailing Address - Country:US
Mailing Address - Phone:262-347-0701
Mailing Address - Fax:262-347-0705
Practice Address - Street 1:N27W23953 PAUL RD
Practice Address - Street 2:STE. 206
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6242
Practice Address - Country:US
Practice Address - Phone:262-347-0701
Practice Address - Fax:262-347-0705
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1920 057103G00000X, 103TC2200X
WI1920103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39126000Medicaid