Provider Demographics
NPI:1073758926
Name:SANDOZ, CHARLES JEFFREY (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JEFFREY
Last Name:SANDOZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21007 BACHMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-3061
Mailing Address - Country:US
Mailing Address - Phone:941-244-9510
Mailing Address - Fax:941-244-9511
Practice Address - Street 1:530 US HIGHWAY 41 BYP S
Practice Address - Street 2:SUITE 4A
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-4750
Practice Address - Country:US
Practice Address - Phone:941-244-9510
Practice Address - Fax:941-244-9511
Is Sole Proprietor?:No
Enumeration Date:2008-12-06
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9693101YM0800X
LA1946101YP2500X
FL4614101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4614OtherCAP