Provider Demographics
NPI:1457819419
Name:DEYO-SONNTAG, CHARISMA L (LPC-IT)
Entity Type:Individual
Prefix:
First Name:CHARISMA
Middle Name:L
Last Name:DEYO-SONNTAG
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 N LYNNDALE DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3059
Mailing Address - Country:US
Mailing Address - Phone:920-385-1420
Mailing Address - Fax:866-327-3295
Practice Address - Street 1:1047 N LYNNDALE DR STE 2B
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3059
Practice Address - Country:US
Practice Address - Phone:920-385-1420
Practice Address - Fax:866-327-3295
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4293-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional