Provider Demographics
NPI:1669672945
Name:PUMPHREY, ROGER MACK (MA, LPC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MACK
Last Name:PUMPHREY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7481 N NAVAJO RD
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3463
Mailing Address - Country:US
Mailing Address - Phone:414-228-6419
Mailing Address - Fax:
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:414-871-9121
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1328-125101YM0800X
WI1157-132101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39668000Medicaid