Provider Demographics
NPI:1356699615
Name:SONNENTAG, SAMANTHA J
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:SONNENTAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6065 JESSICA LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7442
Mailing Address - Country:US
Mailing Address - Phone:920-585-7639
Mailing Address - Fax:
Practice Address - Street 1:5497 W WATERFORD LN
Practice Address - Street 2:SUITE A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8509
Practice Address - Country:US
Practice Address - Phone:920-750-6120
Practice Address - Fax:920-750-6121
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1496-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional