=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083045801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEA CS HUNTER CSAC, LPC, ICS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2013
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5355 ROOT RIVER DR
-----------------------------------------------------
City | GREENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53129-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-914-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5355 ROOT RIVER DR
-----------------------------------------------------
City | GREENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53129-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-914-9787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 16187
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 7854
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------