MEDICARE: SANDBOX CHILD AND FAMILY COUNSELING, PLLC

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	LW60421748	WA
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1265952113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDBOX CHILD AND FAMILY COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	107 W ORCHARD AVE
Second Line	:
City	:	SELAH
State	:	WA
Zip	:	98942-1329
Country	:	US
Telephone Number	:	509-833-6669
Fax Number	:	206-641-7233

Provider Business Practice Location Address
First Line	:	107 W ORCHARD AVE
Second Line	:
City	:	SELAH
State	:	WA
Zip	:	98942-1329
Country	:	US
Telephone Number	:	509-833-6669
Fax Number	:	206-641-7233

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MAGEN HOLGATE
Credential	:	MSW
Telephone Number	:	509-833-6669

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	07/21/2022

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