Healthcare Provider Details

I. General information

NPI: 1871006684
Provider Name (Legal Business Name): BONNIE RACHEL SANDIFER LICDC, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 WHITE POND DR STE C
AKRON OH
44320-4203
US

IV. Provider business mailing address

789 WHITE POND DR STE C
AKRON OH
44320-4203
US

V. Phone/Fax

Practice location:
  • Phone: 866-606-4267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161978
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1904465
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: