Provider Demographics
NPI:1912014291
Name:SARGENT, GREGG (LPC)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:
Last Name:SARGENT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:LORTON II
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-454-6566
Practice Address - Fax:414-454-6527
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI404-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42195000 CLINICMedicaid
00103Medicare ID - Type UnspecifiedMEDICARE PROVIDER