Provider Demographics
NPI:1821597311
Name:RHODE, SARA ROSE (LCSW, CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ROSE
Last Name:RHODE
Suffix:
Gender:F
Credentials:LCSW, CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-8630
Mailing Address - Country:US
Mailing Address - Phone:920-294-4070
Mailing Address - Fax:920-294-4139
Practice Address - Street 1:571 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-4070
Practice Address - Fax:920-294-4139
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9169-1231041C0700X
WI12046-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100075650Medicaid
WI15375-134OtherICS STATE LICENSE
WI100080162OtherMEDICAID- CSAC