Provider Demographics
NPI:1194986588
Name:SEDLAK, LISA JO WEBER (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JO WEBER
Last Name:SEDLAK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JO
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M S
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:WI
Mailing Address - Zip Code:54025-0217
Mailing Address - Country:US
Mailing Address - Phone:715-247-2802
Mailing Address - Fax:715-247-2802
Practice Address - Street 1:2600 65TH AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020
Practice Address - Country:US
Practice Address - Phone:715-294-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI660124106H00000X
MN1054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI810583378018OtherANTHEM BLUE CROSS
MN506S1SEOtherBLUE CROSS BLUE SHIELD
6268361OtherUNITED HEALTHCARE - MEDICA
MN91529OtherHEALTH PARTNERS