Healthcare Provider Details

I. General information

NPI: 1104852813
Provider Name (Legal Business Name): SANDRA GRIFFITH LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 1ST AVE NE
CEDAR RAPIDS IA
52402-5433
US

IV. Provider business mailing address

PO BOX 1408
CEDAR RAPIDS IA
52406-1408
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-3993
  • Fax:
Mailing address:
  • Phone: 319-365-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00239
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1104852813
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: