Provider Demographics
NPI:1205107794
Name:CHARD, PHILIP (MS, LCSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:CHARD
Suffix:
Gender:M
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 QUAIL CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3790
Mailing Address - Country:US
Mailing Address - Phone:262-247-0269
Mailing Address - Fax:
Practice Address - Street 1:1177 QUAIL CT
Practice Address - Street 2:SUITE 101
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3790
Practice Address - Country:US
Practice Address - Phone:262-247-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2206-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical