Healthcare Provider Details

I. General information

NPI: 1821031857
Provider Name (Legal Business Name): SANDRA HARDIE CADCIII, CCSII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 NIAGARA AVE
SHEBOYGAN WI
53081-4128
US

IV. Provider business mailing address

314 NIAGARA AVE
SHEBOYGAN WI
53081-4128
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-8667
  • Fax:
Mailing address:
  • Phone: 920-451-8667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1149
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: