1780714360 NPI number — MRS. SANDRA S WILBUR LCSW BCD

Table of content: MRS. SANDRA S WILBUR LCSW BCD (NPI 1780714360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780714360 NPI number — MRS. SANDRA S WILBUR LCSW BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILBUR
Provider First Name:
SANDRA
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW BCD
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:
1780714360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10229 ASPEN WILLOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-323-7538
Provider Business Mailing Address Fax Number:
703-323-7538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10560 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 510
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-591-8092
Provider Business Practice Location Address Fax Number:
703-323-7538
Provider Enumeration Date:
03/06/2007

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 , 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)

  • Identifier: 043932 . This is a "BCBS ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2697970C2 . This is a "MAMSI OPTIMUM CHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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