Provider Demographics
NPI:1538568910
Name:SANDSTROM, KIMBERLY ANN (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7220
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6830
Practice Address - Fax:920-338-6879
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4736-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional