Provider Demographics
NPI:1659149490
Name:SAMPSON, DEBORAH (LPC-IT, LMT,E-RYT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:LPC-IT, LMT,E-RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 KENWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1477 KENWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1160
Practice Address - Country:US
Practice Address - Phone:920-215-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4800-146225700000X
WI7702-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist