Provider Demographics
NPI:1316531932
Name:CHALK, CAROLINE (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:CHALK
Suffix:
Gender:F
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19114-130101YA0400X
WI4651-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)