Healthcare Provider Details

I. General information

NPI: 1194155887
Provider Name (Legal Business Name): MARVIN MATHIAS SANDIFER MSW, LCSW, LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WARREN ST
GREENSBORO NC
27403-2340
US

IV. Provider business mailing address

PO BOX 13890
GREENSBORO NC
27415-3890
US

V. Phone/Fax

Practice location:
  • Phone: 336-517-3770
  • Fax: 336-517-3783
Mailing address:
  • Phone: 336-621-3381
  • Fax: 336-621-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC007317
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: