Provider Demographics
NPI:1821568437
Name:CHESLOCK, JOHN R (MA, LPC-IT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:CHESLOCK
Suffix:
Gender:M
Credentials:MA, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:626 S IRWIN AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3304
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4107101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor