Provider Demographics
NPI:1033126198
Name:ROELLICH, SANDRA A (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:ROELLICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:238 FRONT STREET - SCENIC BLUFFS HEALTH CENTER
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619
Mailing Address - Country:US
Mailing Address - Phone:608-654-5100
Mailing Address - Fax:608-654-5120
Practice Address - Street 1:238 FRONT STREET
Practice Address - Street 2:SCENIC BLUFFS HEALTH CENTER
Practice Address - City:CASHTON
Practice Address - State:WI
Practice Address - Zip Code:54619
Practice Address - Country:US
Practice Address - Phone:608-654-5100
Practice Address - Fax:608-654-5120
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WICERT #1344101YA0400X
WI13781041C0700X
WI1378-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39290700Medicaid
WI39290700Medicaid
WI521808Medicare Oscar/Certification
WIR76555Medicare UPIN
R76555Medicare UPIN