Provider Demographics
NPI:1427704576
Name:JOSE, SANDRA ELAINE (LSW-C)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELAINE
Last Name:JOSE
Suffix:
Gender:F
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 STATE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1147
Mailing Address - Country:US
Mailing Address - Phone:207-899-5822
Mailing Address - Fax:
Practice Address - Street 1:28 STATE ST STE 5
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1147
Practice Address - Country:US
Practice Address - Phone:207-899-5822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX20975104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOTHERMedicaid