Provider Demographics
NPI:1699928440
Name:WALLACE -TOMCZAK, SARA NAOMI (SACIT, MT, IDP-AT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:NAOMI
Last Name:WALLACE -TOMCZAK
Suffix:
Gender:F
Credentials:SACIT, MT, IDP-AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6109
Mailing Address - Country:US
Mailing Address - Phone:715-835-9110
Mailing Address - Fax:715-830-4098
Practice Address - Street 1:3136 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6109
Practice Address - Country:US
Practice Address - Phone:715-835-9110
Practice Address - Fax:715-830-4098
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14558-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)