Provider Demographics
NPI:1154696086
Name:GORMON-BROWN, SANDRA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:GORMON-BROWN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N 1212 WASHINGTON
Mailing Address - Street 2:GRASSROOTS THERAPY GROUP SUITE 204
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201
Mailing Address - Country:US
Mailing Address - Phone:509-279-8838
Mailing Address - Fax:509-267-2717
Practice Address - Street 1:N 1212 WASHINGTON
Practice Address - Street 2:GRASSROOTS THERAPY GROUP SUITE 204
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-279-8838
Practice Address - Fax:509-464-6239
Is Sole Proprietor?:No
Enumeration Date:2012-03-10
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000066661041C0700X
WALW601858851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041796Medicaid