Healthcare Provider Details

I. General information

NPI: 1083854046
Provider Name (Legal Business Name): DANIELLE BLACKWOOD SANDAGE LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE BOSTON CHILDREN'S HOSPITAL
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE BOSTON CHILDREN'S HOSPITAL
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7965
  • Fax: 617-730-0208
Mailing address:
  • Phone: 617-355-7491
  • Fax: 617-730-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13483
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: