Provider Demographics
NPI:1962500769
Name:TARVID, SALLY SUE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:SUE
Last Name:TARVID
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 PILGRIM PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2067
Mailing Address - Country:US
Mailing Address - Phone:414-491-0377
Mailing Address - Fax:
Practice Address - Street 1:740 PILGRIM PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2067
Practice Address - Country:US
Practice Address - Phone:414-491-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70991231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40967200Medicaid
WI40967200Medicaid