Provider Demographics
NPI:1699939371
Name:BOULANGER, SANDNES SMITH (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SANDNES
Middle Name:SMITH
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5918
Mailing Address - Country:US
Mailing Address - Phone:727-504-2427
Mailing Address - Fax:813-864-1318
Practice Address - Street 1:10909 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2511
Practice Address - Country:US
Practice Address - Phone:813-864-1421
Practice Address - Fax:813-864-1318
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW66381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76412100Medicaid