1639695380 NPI number — MRS. COURTNI BROOKE SANDRAS-GAUT LCSW

Table of content: MRS. COURTNI BROOKE SANDRAS-GAUT LCSW (NPI 1639695380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639695380 NPI number — MRS. COURTNI BROOKE SANDRAS-GAUT LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDRAS-GAUT
Provider First Name:
COURTNI
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639695380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 541
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24003-0541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-400-7431
Provider Business Mailing Address Fax Number:
540-400-7091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 CAMPBELL AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24016-3627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-400-7431
Provider Business Practice Location Address Fax Number:
540-400-7091
Provider Enumeration Date:
08/15/2017

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 , with the licence number:  0904010061 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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