Healthcare Provider Details

I. General information

NPI: 1801230818
Provider Name (Legal Business Name): CHANDA SPRAGUE SOCIAL WORK INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2013
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WAREHAM LAKE SHORE DR
EAST WAREHAM MA
02538-1437
US

IV. Provider business mailing address

113 WAREHAM LAKE SHORE DR
EAST WAREHAM MA
02538-1437
US

V. Phone/Fax

Practice location:
  • Phone: 702-785-7845
  • Fax:
Mailing address:
  • Phone: 702-785-7845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA015971
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN15350
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: