Healthcare Provider Details

I. General information

NPI: 1669672945
Provider Name (Legal Business Name): ROGER MACK PUMPHREY MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 W LISBON AVE SUITE 102
MILWAUKEE WI
53210-2116
US

IV. Provider business mailing address

7481 N NAVAJO RD
FOX POINT WI
53217-3463
US

V. Phone/Fax

Practice location:
  • Phone: 414-871-9111
  • Fax: 414-871-9121
Mailing address:
  • Phone: 414-228-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1328-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1157-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: