Provider Demographics
NPI:1952757767
Name:SANFORD, MARY (PC-IT; SAC-IT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PC-IT; SAC-IT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PC-IT; SAC-IT
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:6110 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2120
Practice Address - Country:US
Practice Address - Phone:414-393-0295
Practice Address - Fax:414-393-1155
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)