Basic Information
| Provider Information | |||||||||
| NPI: | 1457858342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 923 FINDLAY ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403543829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 508 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST UNION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456938002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375445218 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 165998 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | QMHS | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | LCDCII.161621 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0274897 | 05 | OH | MEDICAID |