Provider Demographics
NPI:1619011046
Name:SEBASTIAN FAMILY PSYCHOLOGY PRACTICE, LLC
Entity Type:Organization
Organization Name:SEBASTIAN FAMILY PSYCHOLOGY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SSEMPIJJA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:414-915-2967
Mailing Address - Street 1:6025 N GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3811
Mailing Address - Country:US
Mailing Address - Phone:414-247-0801
Mailing Address - Fax:414-247-0816
Practice Address - Street 1:6025 N GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3811
Practice Address - Country:US
Practice Address - Phone:414-247-0801
Practice Address - Fax:414-247-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-18
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1784-057103T00000X, 103TB0200X, 103TC0700X, 103TC2200X
WI126576-121104100000X
WI3079-123104100000X
WI302-123104100000X
WI160-123104100000X
171R00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42236700Medicaid