Healthcare Provider Details

I. General information

NPI: 1053412882
Provider Name (Legal Business Name): SANDRA C RANGE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WILLARD ST SUITE 430
QUINCY MA
02169-7482
US

IV. Provider business mailing address

313 CENTRAL ST
AVON MA
02322-1532
US

V. Phone/Fax

Practice location:
  • Phone: 617-847-1944
  • Fax:
Mailing address:
  • Phone: 781-767-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5509
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: