Basic Information
Provider Information | |||||||||
NPI: | 1366410144 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UNTIED | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, BSN, MSW, LISW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6481 WELSH RD | ||||||||
Address2: |   | ||||||||
City: | NASHPORT | ||||||||
State: | OH | ||||||||
PostalCode: | 438309512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404549841 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2845 BELL ST | ||||||||
Address2: |   | ||||||||
City: | ZANESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437011720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404549766 | ||||||||
FaxNumber: | 7405886452 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I7480 | OH | X |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163WP0808X | RN100389 | OH | X |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 218931 | 01 | OH | TRICARE/MHN PIN | OTHER | 9071405 | 01 | OH | PRIVATE HLTHCARE SYS PIN | OTHER | 000000218890 | 01 | OH | ANTHEM PIN | OTHER | 246101 | 01 | OH | MOUNT CARMEL PIN | OTHER | 7602165 | 01 | OH | AETNA PIN | OTHER | 2032248 | 01 | OH | CIGNA BH PIN | OTHER | Y555056 | 01 | OH | THE HEALTH PLAN PIN | OTHER |