Provider Demographics
NPI:1316486731
Name:SANDBERG, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:M
Credentials:
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 11
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-0011
Mailing Address - Country:US
Mailing Address - Phone:608-632-3286
Mailing Address - Fax:
Practice Address - Street 1:118 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1613
Practice Address - Country:US
Practice Address - Phone:608-632-3286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI9208-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health