Provider Demographics
NPI:1811269004
Name:SUBROD, JAMES EDWARD (SAC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:SUBROD
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1811
Mailing Address - Country:US
Mailing Address - Phone:262-763-6688
Mailing Address - Fax:
Practice Address - Street 1:201 N PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1935
Practice Address - Country:US
Practice Address - Phone:262-767-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11645-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)