Provider Demographics
NPI:1427228436
Name:SHAFFER, SANDRA MARIE (LCSW, CSAC, ICS)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:MARIE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:LCSW, CSAC, ICS
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:FLEISCHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, CSAC, ICS
Mailing Address - Street 1:3475 OMRO RD STE 400
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7126
Mailing Address - Country:US
Mailing Address - Phone:920-267-3470
Mailing Address - Fax:920-267-3480
Practice Address - Street 1:3475 OMRO RD STE 400
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7126
Practice Address - Country:US
Practice Address - Phone:920-203-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15806-132101YA0400X
WI8484-123101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102138Medicaid
WI1184230351OtherNPI-TYPE 2