Provider Demographics
NPI:1063966331
Name:BATES, SANDRA L (LMSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:BATES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 SHAVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6744
Mailing Address - Country:US
Mailing Address - Phone:269-993-0112
Mailing Address - Fax:
Practice Address - Street 1:10332 SHAVER RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6744
Practice Address - Country:US
Practice Address - Phone:269-993-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011001211041C0700X
MI68011150311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical