Healthcare Provider Details

I. General information

NPI: 1609030162
Provider Name (Legal Business Name): SANDY J WAITE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34010 88TH AVE
LAWTON MI
49065-9302
US

IV. Provider business mailing address

34010 88TH AVE
LAWTON MI
49065-9302
US

V. Phone/Fax

Practice location:
  • Phone: 269-624-6473
  • Fax:
Mailing address:
  • Phone: 269-624-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801083312
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: