Healthcare Provider Details

I. General information

NPI: 1699228924
Provider Name (Legal Business Name): SANDRA KOTECKI LBSW, QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA LYNN MESLER LBSW, QIDP

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 E APPLE AVE
MUSKEGON MI
49442-3466
US

IV. Provider business mailing address

27 S BOCK RD
MUSKEGON MI
49442-1905
US

V. Phone/Fax

Practice location:
  • Phone: 231-724-1368
  • Fax: 231-724-4539
Mailing address:
  • Phone: 231-736-2608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802082903
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: