Provider Demographics
NPI:1144264375
Name:KRAVICK, SARAH J (LMFT)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:J
Last Name:KRAVICK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:J
Other - Last Name:DIEFENTHALER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:627 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1458
Mailing Address - Country:US
Mailing Address - Phone:608-745-1799
Mailing Address - Fax:
Practice Address - Street 1:2639 NEW PINERY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1110
Practice Address - Country:US
Practice Address - Phone:608-742-5020
Practice Address - Fax:608-742-3641
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI659-124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13570OtherDEAN INSURANCE CO.
WI40923800Medicaid