Provider Demographics
NPI:1720169634
Name:STEVENS, SALLY J (MSSW, LCSW, CADC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MSSW, LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 JOHN NOLEN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1465
Mailing Address - Country:US
Mailing Address - Phone:608-256-5030
Mailing Address - Fax:608-256-5038
Practice Address - Street 1:900 JOHN NOLEN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1465
Practice Address - Country:US
Practice Address - Phone:608-256-5030
Practice Address - Fax:608-256-5038
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12695101YA0400X
WI3500-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39579700Medicaid