1750949228 NPI number — MISS SANDRA ELLEN FORTSON MSW, LCSW

Table of content: MISS SANDRA ELLEN FORTSON MSW, LCSW (NPI 1750949228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750949228 NPI number — MISS SANDRA ELLEN FORTSON MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTSON
Provider First Name:
SANDRA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MSW, 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:
1750949228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8665 CANDLEWOOD ST APT 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48116-2335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-239-1599
Provider Business Mailing Address Fax Number:
970-449-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8665 CANDLEWOOD ST APT 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48116-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-239-1599
Provider Business Practice Location Address Fax Number:
970-449-0429
Provider Enumeration Date:
05/30/2019

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:  LCSW119466 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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