Provider Demographics
NPI:1649671629
Name:LEE YANG, SHENG BOUALONG (LCSW)
Entity type:Individual
Prefix:
First Name:SHENG
Middle Name:BOUALONG
Last Name:LEE YANG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 W GRANDE MARKET DR STE A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8406
Mailing Address - Country:US
Mailing Address - Phone:920-903-1060
Mailing Address - Fax:902-906-1164
Practice Address - Street 1:119 N MCCARTHY RD STE P
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9112
Practice Address - Country:US
Practice Address - Phone:920-903-1060
Practice Address - Fax:902-906-1164
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8613-123101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042518Medicaid