Provider Demographics
NPI:1891911749
Name:THEODOR, SANDRA ANN (LICSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:ANN
Last Name:THEODOR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 CRANMORE LN
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-1507
Mailing Address - Country:US
Mailing Address - Phone:781-662-1185
Mailing Address - Fax:
Practice Address - Street 1:151 MYSTIC AVE
Practice Address - Street 2:STE 6, DCS MENTAL HEALTH INC.
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4632
Practice Address - Country:US
Practice Address - Phone:781-396-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10290701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical