Provider Demographics
NPI:1477174381
Name:ROSS, SARAH (SAC-IT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:LA CLINICA DE LOS CAMPESINOS, INC.
Mailing Address - Street 2:PO BOX 1440
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:302 WEST LAKE ST.
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:55934
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:920-787-4737
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18665-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)