MEDICARE: GENELL G SANDBERG PHD

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	103T00000X	Psychologist	00562	IA

General Provider Information

NPI Number	:	1851375802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENELL G SANDBERG PHD

Provider Business Mailing Address
First Line	:	2601 APACHE CT
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-1504
Country	:	US
Telephone Number	:	712-239-1111
Fax Number	:	712-239-1199

Provider Business Practice Location Address
First Line	:	2601 APACHE CT
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-1504
Country	:	US
Telephone Number	:	712-239-1111
Fax Number	:	712-239-1199

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	03/10/2011

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