Healthcare Provider Details

I. General information

NPI: 1568565992
Provider Name (Legal Business Name): SANDRA DAHL RONAN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA L. DAHL RONAN

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 PROSPECT ST
GLOUCESTER MA
01930-3710
US

IV. Provider business mailing address

92 PROSPECT ST
GLOUCESTER MA
01930-3710
US

V. Phone/Fax

Practice location:
  • Phone: 978-281-4067
  • Fax:
Mailing address:
  • Phone: 978-281-4067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103955
License Number StateMA

VII. Legacy identifiers

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

# 1
Identifier0596419
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 2
Identifier1013896
Identifier TypeOTHER
Identifier State
Identifier IssuerCIGNA
# 3
Identifier721517
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerTUFTS
# 4
Identifier000531000
Identifier TypeOTHER
Identifier State
Identifier IssuerMAGELLAN
# 5
Identifier1006790
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBEACON

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: