Provider Demographics
NPI:1104585959
Name:CONSTANTINE, SARAH POTTER
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:POTTER
Last Name:CONSTANTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 GOLF TER STE 207
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4688
Mailing Address - Country:US
Mailing Address - Phone:715-514-0493
Mailing Address - Fax:877-855-2504
Practice Address - Street 1:4330 GOLF TER STE 207
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4688
Practice Address - Country:US
Practice Address - Phone:715-514-0493
Practice Address - Fax:877-855-2504
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10631-125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104585959Medicaid
WI100191002Medicaid