Provider Demographics
NPI:1851441034
Name:BUB-STANDAL, CARYN (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:BUB-STANDAL
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:414-325-7753
Practice Address - Street 1:4811 S. 76TH ST.
Practice Address - Street 2:STE. 401
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220
Practice Address - Country:US
Practice Address - Phone:414-325-7741
Practice Address - Fax:414-325-7753
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI471-124106H00000X
WI186-124106H00000X
WI2792-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391805443007OtherBCBS
WI39645500Medicaid