Provider Demographics
NPI:1023199338
Name:FORTIER, SANDRA M (LISW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:FORTIER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CAMINO MESTENO
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8623
Mailing Address - Country:US
Mailing Address - Phone:505-771-9279
Mailing Address - Fax:
Practice Address - Street 1:4351 JAGER DR NE
Practice Address - Street 2:SUITE C
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7523
Practice Address - Country:US
Practice Address - Phone:505-410-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-068751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical