Healthcare Provider Details

I. General information

NPI: 1265147219
Provider Name (Legal Business Name): CODY KENNETH SWEENEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2459 W PERSHING ST APT 22
APPLETON WI
54914-6038
US

IV. Provider business mailing address

2459 W PERSHING ST APT 22
APPLETON WI
54914-6038
US

V. Phone/Fax

Practice location:
  • Phone: 715-412-2401
  • Fax:
Mailing address:
  • Phone: 715-412-2401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10725-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: