Provider Demographics
NPI:1215291950
Name:SACK, KRISTINE KAY (LPC)
Entity type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:KAY
Last Name:SACK
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 1:926 WILLARD DRIVE
Mailing Address - Street 2:STE 136
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5071
Mailing Address - Country:US
Mailing Address - Phone:920-461-5820
Mailing Address - Fax:888-449-6342
Practice Address - Street 1:926 WILLARD DRIVE
Practice Address - Street 2:STE 136
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5071
Practice Address - Country:US
Practice Address - Phone:920-461-5820
Practice Address - Fax:888-449-6342
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5307-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-0816846Medicaid