Provider Demographics
NPI:1447873484
Name:WILSON, SADIE CHEYENNE (LPC-IT)
Entity type:Individual
Prefix:
First Name:SADIE
Middle Name:CHEYENNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2931
Mailing Address - Country:US
Mailing Address - Phone:920-471-9872
Mailing Address - Fax:
Practice Address - Street 1:5750 W GRANDE MARKET DR STE A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8406
Practice Address - Country:US
Practice Address - Phone:920-903-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health