MEDICARE: SANDRA LEE FELDMAN MSW, 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	6801092680	MI

General Provider Information

NPI Number	:	1700188570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA LEE FELDMAN MSW, LCSW

Provider Business Mailing Address
First Line	:	PO BOX 57
Second Line	:
City	:	LAKESIDE
State	:	MI
Zip	:	49116-0057
Country	:	US
Telephone Number	:	269-921-2953
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 LESTER AVE
Second Line	:	SUITE B10
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2561
Country	:	US
Telephone Number	:	269-921-2953
Fax Number	:

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

Provider Enumeration Date	:	11/29/2010
Last Update Date	:	11/29/2010

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