Provider Demographics
NPI:1700222338
Name:TEGGE, JUDITH GERALYN (LPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:GERALYN
Last Name:TEGGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:GERALYN
Other - Last Name:HEEZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5555 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4929
Mailing Address - Country:US
Mailing Address - Phone:262-789-1191
Mailing Address - Fax:414-967-7965
Practice Address - Street 1:5555 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4929
Practice Address - Country:US
Practice Address - Phone:262-789-1191
Practice Address - Fax:414-967-7965
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000-088745OtherGROUP MEDICARE (P-TAN) MILWAUKEE COUNTY
WI42170300Medicaid