Provider Demographics
NPI:1205009354
Name:SARDINA, LILLIAN M (MS, ICS, CSAC, LPC)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:M
Last Name:SARDINA
Suffix:
Gender:F
Credentials:MS, ICS, CSAC, LPC
Other - Prefix:
Other - First Name:LILLIAN
Other - Middle Name:M
Other - Last Name:BENAVIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADAC, CI
Mailing Address - Street 1:930 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-383-9526
Mailing Address - Fax:414-229-2912
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-383-9526
Practice Address - Fax:414-671-6606
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1965-132101YA0400X
WI11226-135101YA0400X
WI7502-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39362500Medicaid