Healthcare Provider Details

I. General information

NPI: 1700230570
Provider Name (Legal Business Name): LINDA SANDERVILLE MSW, LICSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LINDA PEPERA

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 PARADISE BLVD NW UNIT 66884
ALBUQUERQUE NM
87193-4978
US

IV. Provider business mailing address

4600 PARADISE BLVD NW UNIT 66884
ALBUQUERQUE NM
87193-4978
US

V. Phone/Fax

Practice location:
  • Phone: 505-317-7444
  • Fax: 505-461-1456
Mailing address:
  • Phone: 505-317-7444
  • Fax: 505-461-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTPSW810
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904011329
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079629
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15358
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10250
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: