Healthcare Provider Details

I. General information

NPI: 1518971324
Provider Name (Legal Business Name): CHRISTINE CHIYE TSUBOKURA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 PROFESSIONAL DR UPLANDS COUNSELING ASSOC
DODGEVILLE WI
53533-1176
US

IV. Provider business mailing address

1118 PROFESSIONAL DR UPLANDS COUNSELING ASSOC
DODGEVILLE WI
53533-1176
US

V. Phone/Fax

Practice location:
  • Phone: 608-935-2838
  • Fax: 608-935-9227
Mailing address:
  • Phone: 608-935-2838
  • Fax: 608-935-9227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2304-123
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2304-123
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2304-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: