=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467788695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDY A BARTRAM LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2009
-----------------------------------------------------
Last Update Date | 10/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 E PARK AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44446-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-544-8005
-----------------------------------------------------
Fax | 330-544-9379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2932 VERA AVE
-----------------------------------------------------
City | SOUTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44470-9500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-974-8069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | S0901174
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------