1215164322 NPI number — MS. SANDY RUBY SEWELL LICSW, CMHS

Table of content: MS. SANDY RUBY SEWELL LICSW, CMHS (NPI 1215164322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215164322 NPI number — MS. SANDY RUBY SEWELL LICSW, CMHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEWELL
Provider First Name:
SANDY
Provider Middle Name:
RUBY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW, CMHS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEWELL
Provider Other First Name:
SANDY
Provider Other Middle Name:
RUBY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW, CMHS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215164322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98666-0091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-607-6017
Provider Business Mailing Address Fax Number:
360-750-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 MAIN ST
Provider Second Line Business Practice Location Address:
STE 214
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98660-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-607-6017
Provider Business Practice Location Address Fax Number:
360-750-1374
Provider Enumeration Date:
06/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LW60271794 . This is a "LICSW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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