Provider Demographics
NPI:1104866888
Name:BRAGG, SANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BRAGG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 PATTIE LN
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28555-9481
Mailing Address - Country:US
Mailing Address - Phone:910-389-0420
Mailing Address - Fax:910-989-3200
Practice Address - Street 1:825 GUM BRANCH RD SUITE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-989-0700
Practice Address - Fax:910-989-3200
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0020531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical