=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114150026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA JEAN DEAN LAPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2009
-----------------------------------------------------
Last Update Date | 08/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 786 RIVERBEND RD
-----------------------------------------------------
City | DAWSONVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30534-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-216-6356
-----------------------------------------------------
Fax | 706-265-6295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1676 DEER TRAIL LAKES DR
-----------------------------------------------------
City | CLARKESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30523-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-839-4284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | APC001463
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------