Healthcare Provider Details

I. General information

NPI: 1598743239
Provider Name (Legal Business Name): THERESA MARIE SHUCK MS,MA,LCGC,LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 05/07/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 WATERTOWN PLANK RD #106
ELM GROVE WI
53122-7503
US

IV. Provider business mailing address

2112 ANDY JOHN CT
GREEN BAY WI
54311-6371
US

V. Phone/Fax

Practice location:
  • Phone: 414-807-8934
  • Fax:
Mailing address:
  • Phone: 920-606-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: