Basic Information
| Provider Information | |||||||||
| NPI: | 1215164322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEWELL | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | RUBY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW, CMHS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEWELL | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | RUBY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW, CMHS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 91 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986660091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606076017 | ||||||||
| FaxNumber: | 3607501374 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 MAIN ST | ||||||||
| Address2: | STE 214 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986603402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606076017 | ||||||||
| FaxNumber: | 3607501374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 05/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LW60271794 | 01 | WA | LICSW | OTHER |