MEDICARE: MRS. MELBA B SANDIFER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1996	LA

General Provider Information

NPI Number	:	1043513690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELBA B SANDIFER LCSW

Provider Business Mailing Address
First Line	:	708 E MAIN ST
Second Line	:
City	:	OAK GROVE
State	:	LA
Zip	:	71263-2500
Country	:	US
Telephone Number	:	318-428-9000
Fax Number	:	318-428-9759

Provider Business Practice Location Address
First Line	:	708 E MAIN ST
Second Line	:
City	:	OAK GROVE
State	:	LA
Zip	:	71263-2500
Country	:	US
Telephone Number	:	318-428-9000
Fax Number	:	318-428-9759

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2010
Last Update Date	:	12/20/2010

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