Healthcare Provider Details

I. General information

NPI: 1376869057
Provider Name (Legal Business Name): SANDRA ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 03/12/2021
Certification Date: 02/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19150 S. KEDZIE AVE SUITE 200
FLOSSMOOR IL
60411
US

IV. Provider business mailing address

595 YORKTOWN RD
CHICAGO HEIGHTS IL
60411-1922
US

V. Phone/Fax

Practice location:
  • Phone: 708-752-5306
  • Fax:
Mailing address:
  • Phone: 708-752-5306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149008499
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-008499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: