Basic Information
| Provider Information | |||||||||
| NPI: | 1891162046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRITTON | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAVIN | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622993040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 W GLEN OAKS LN STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530923392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622446177 | ||||||||
| FaxNumber: | 2622443040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2015 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2663-226 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 100048028 | 05 | WI | MEDICAID |