Provider Demographics
NPI:1548376726
Name:LIPUSCH, JAMES THOMAS (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:THOMAS
Last Name:LIPUSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 LAKE ST #501
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGOTN
Mailing Address - State:WI
Mailing Address - Zip Code:53074
Mailing Address - Country:US
Mailing Address - Phone:262-893-6121
Mailing Address - Fax:262-284-6618
Practice Address - Street 1:3425 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-458-5557
Practice Address - Fax:920-458-2692
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20801231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical