Provider Demographics
NPI:1023216132
Name:FORTUNA, SANDRA ELLEN (BSW)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ELLEN
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:ELLEN
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:500 E 9TH ST
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-0662
Mailing Address - Country:US
Mailing Address - Phone:605-842-1465
Mailing Address - Fax:605-842-2366
Practice Address - Street 1:500 E 9TH ST
Practice Address - Street 2:
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-0662
Practice Address - Country:US
Practice Address - Phone:605-842-1465
Practice Address - Fax:605-842-2366
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1248104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker