Provider Demographics
NPI:1225201817
Name:VANDOMELEN, SANDRA M (SAC-IT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:VANDOMELEN
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 W SCHROEDER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1475
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:9415 W FOREST HOME AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1680
Practice Address - Country:US
Practice Address - Phone:414-427-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15463-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)