Basic Information
| Provider Information | |||||||||
| NPI: | 1699939371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULANGER | ||||||||
| FirstName: | SANDNES | ||||||||
| MiddleName: | SMITH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 522 39TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337035918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275042427 | ||||||||
| FaxNumber: | 8138641318 | ||||||||
| Practice Location | |||||||||
| Address1: | 10909 MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138641421 | ||||||||
| FaxNumber: | 8138641318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW6638 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 76412100 | 05 | FL | MEDICAID |