Provider Demographics
NPI:1740300821
Name:PRINCIPE, SANDRA J (SAC, PS)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:PRINCIPE
Suffix:
Gender:F
Credentials:SAC, PS
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:J
Other - Last Name:AGOSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC, PS
Mailing Address - Street 1:620 PRENTICE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3343
Mailing Address - Country:US
Mailing Address - Phone:715-682-6130
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-5400
Practice Address - Fax:715-685-5102
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11556-137101YA0400X
WI15183-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)