Healthcare Provider Details

I. General information

NPI: 1447873484
Provider Name (Legal Business Name): SADIE CHEYENNE WILSON LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W GRANDE MARKET DR STE A
APPLETON WI
54913-8406
US

IV. Provider business mailing address

214 S ONTARIO ST
DE PERE WI
54115-2931
US

V. Phone/Fax

Practice location:
  • Phone: 920-903-1060
  • Fax:
Mailing address:
  • Phone: 920-471-9872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: