Healthcare Provider Details

I. General information

NPI: 1477068096
Provider Name (Legal Business Name): TRACY LYNN SINEWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 S MONROE AVE STE 201
GREEN BAY WI
54301-4054
US

IV. Provider business mailing address

424 S MONROE AVE STE 201
GREEN BAY WI
54301-4054
US

V. Phone/Fax

Practice location:
  • Phone: 920-445-0170
  • Fax: 920-445-0174
Mailing address:
  • Phone: 920-445-0170
  • Fax: 920-445-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19126-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801101841
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: