MEDICARE: MRS. SANDRA H POVOA 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	C004902	NC

General Provider Information

NPI Number	:	1417497348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA H POVOA LCSW

Provider Business Mailing Address
First Line	:	PO BOX 39462
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-1026
Country	:	US
Telephone Number	:	704-576-5996
Fax Number	:

Provider Business Practice Location Address
First Line	:	8832 BLAKENEY PROFESSIONAL DR STE 103
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-6717
Country	:	US
Telephone Number	:	704-576-5996
Fax Number	:

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

Provider Enumeration Date	:	02/25/2017
Last Update Date	:	01/26/2022

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