Healthcare Provider Details

I. General information

NPI: 1114447273
Provider Name (Legal Business Name): SHANEN SADOWSKI LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5497 W WATERFORD LN
APPLETON WI
54913-8509
US

IV. Provider business mailing address

907 N BADGER AVE
APPLETON WI
54914-3346
US

V. Phone/Fax

Practice location:
  • Phone: 920-750-6120
  • Fax:
Mailing address:
  • Phone: 920-265-4087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3561-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3561-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: