Basic Information
| Provider Information | |||||||||
| NPI: | 1083850796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAEBER | ||||||||
| FirstName: | SHERYL | ||||||||
| MiddleName: | L. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1570 MIDWAY PL | ||||||||
| Address2: | |||||||||
| City: | MENASHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549521165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207201464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 515 S WASHBURN ST | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202368570 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12903-131 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 3374-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 43745330 | 05 | WI | MEDICAID |