Healthcare Provider Details

I. General information

NPI: 1831808047
Provider Name (Legal Business Name): OUR CREATED LIVES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2454 MORGAN LN
GREEN BAY WI
54311-5509
US

IV. Provider business mailing address

2454 MORGAN LN
GREEN BAY WI
54311-5509
US

V. Phone/Fax

Practice location:
  • Phone: 920-245-5090
  • Fax:
Mailing address:
  • Phone: 920-245-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARAH SIEBERT
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: MA, LPC
Phone: 920-245-5090