Healthcare Provider Details

I. General information

NPI: 1801939467
Provider Name (Legal Business Name): KEN SANN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 W MASON ST SUITE 200
GREEN BAY WI
54303-2049
US

IV. Provider business mailing address

1345 W MASON ST SUITE 200
GREEN BAY WI
54303-2049
US

V. Phone/Fax

Practice location:
  • Phone: 920-438-8141
  • Fax: 920-438-7993
Mailing address:
  • Phone: 920-438-8141
  • Fax: 920-438-7993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1722-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2313
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2221-120
License Number StateWI

VIII. Authorized Official

Name: KENNETH ROY SANN
Title or Position: OWNER
Credential:
Phone: 920-438-8141