=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154278083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SANDBOX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2026
-----------------------------------------------------
Last Update Date | 03/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 D ST
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25303-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-887-2994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 D ST
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25303-3103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-887-3540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLY DADISMAN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 304-887-3540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------