MEDICARE: SACRED WANDERING / SACRED PATH PRACTITIONERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1780240614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED WANDERING / SACRED PATH PRACTITIONERS

Provider Business Mailing Address
First Line	:	10134 N PORT WASHINGTON RD STE G
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5700
Country	:	US
Telephone Number	:	414-433-9193
Fax Number	:	414-435-9611

Provider Business Practice Location Address
First Line	:	10134 N PORT WASHINGTON RD STE G
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5700
Country	:	US
Telephone Number	:	414-433-9193
Fax Number	:	414-435-9611

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	KENNETH J NELAN
Credential	:	MS, LPC, NCC
Telephone Number	:	414-433-9193

Provider Enumeration Date	:	05/16/2019
Last Update Date	:	05/16/2019

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