Provider Demographics
NPI:1063178937
Name:SANDRA E. FORTSON, LCSW, LLC
Entity type:Organization
Organization Name:SANDRA E. FORTSON, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:970-239-1599
Mailing Address - Street 1:8665 CANDLEWOOD ST APT 8
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2335
Mailing Address - Country:US
Mailing Address - Phone:970-239-1559
Mailing Address - Fax:970-449-0429
Practice Address - Street 1:8665 CANDLEWOOD ST APT 8
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2335
Practice Address - Country:US
Practice Address - Phone:970-239-1559
Practice Address - Fax:970-449-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-15
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty