Healthcare Provider Details

I. General information

NPI: 1609608538
Provider Name (Legal Business Name): CHARLINE STEPHANIE HART SHEEHAN APSW, SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3105
  • Fax: 920-674-6113
Mailing address:
  • Phone: 920-674-3105
  • Fax: 920-674-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20745-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135863
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: