Provider Demographics
NPI:1699228924
Name:KOTECKI, SANDRA (LBSW, QIDP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KOTECKI
Suffix:
Gender:F
Credentials:LBSW, QIDP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:MESLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW, QIDP
Mailing Address - Street 1:27 S BOCK RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-1905
Mailing Address - Country:US
Mailing Address - Phone:231-736-2608
Mailing Address - Fax:
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:231-724-1368
Practice Address - Fax:231-724-4539
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802082903104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker