Provider Demographics
NPI:1760685820
Name:SUBURBAN COUNSELING SERVICES
Entity Type:Organization
Organization Name:SUBURBAN COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-550-9350
Mailing Address - Street 1:1208 HWY 83
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8313
Mailing Address - Country:US
Mailing Address - Phone:414-550-9350
Mailing Address - Fax:262-369-7752
Practice Address - Street 1:1208 HWY 83
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-8313
Practice Address - Country:US
Practice Address - Phone:414-550-9350
Practice Address - Fax:262-369-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2243-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1889OtherSTATE CERTIFICATION #:
WI000002607OtherMEDICARE GROUP ID#: