Provider Demographics
NPI:1093772865
Name:SANDBERG, LAURA R (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:SANDBERG
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 679
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54903-0679
Mailing Address - Country:US
Mailing Address - Phone:920-233-4557
Mailing Address - Fax:920-233-5644
Practice Address - Street 1:303 PEARL AVE
Practice Address - Street 2:SUITE C
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4774
Practice Address - Country:US
Practice Address - Phone:920-233-4557
Practice Address - Fax:920-233-5644
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6616-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39779900Medicaid