Healthcare Provider Details

I. General information

NPI: 1821597311
Provider Name (Legal Business Name): SARA ROSE RHODE LCSW, CSAC, ICS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 COUNTY ROAD A
GREEN LAKE WI
54941
US

IV. Provider business mailing address

571 COUNTY ROAD A
GREEN LAKE WI
54941-8630
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-4070
  • Fax: 920-294-4139
Mailing address:
  • Phone: 920-294-4070
  • Fax: 920-294-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9169-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12046-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: