Healthcare Provider Details

I. General information

NPI: 1851441034
Provider Name (Legal Business Name): CARYN BUB-STANDAL LCSW, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S. 76TH ST. STE. 401
GREENFIELD WI
53220
US

IV. Provider business mailing address

4811 S 76TH ST STE 305
GREENFIELD WI
53220-4364
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7741
  • Fax: 414-325-7753
Mailing address:
  • Phone: 414-325-7741
  • Fax: 414-325-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number471-124
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number186-124
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2792-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: