Healthcare Provider Details

I. General information

NPI: 1023050382
Provider Name (Legal Business Name): SANDY IMANSE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 LINCOLNWAY W
MISHAWAKA IN
46544-1626
US

IV. Provider business mailing address

PO BOX 809
GOSHEN IN
46527-0809
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-5669
  • Fax: 574-537-2652
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801018351
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33002493A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: