Provider Demographics
NPI:1578018263
Name:SANFORD, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:SANFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC-IT / CSAC-IT
Mailing Address - Street 1:12645 W BURLEIGH RD STE 19
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3102
Mailing Address - Country:US
Mailing Address - Phone:262-432-0670
Mailing Address - Fax:262-475-0412
Practice Address - Street 1:12645 W BURLEIGH RD STE 19
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3102
Practice Address - Country:US
Practice Address - Phone:262-432-0670
Practice Address - Fax:262-475-0412
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4810-226101YP2500X
WI17676-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional