Provider Demographics
NPI:1538408141
Name:LORGE, CHAD THOMAS (MSE, NCC)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:THOMAS
Last Name:LORGE
Suffix:
Gender:M
Credentials:MSE, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 1/2 E DOTY AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2975
Mailing Address - Country:US
Mailing Address - Phone:920-707-3110
Mailing Address - Fax:
Practice Address - Street 1:1478 KENWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-886-9319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1646-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional