Provider Demographics
NPI:1225089212
Name:BOTHWICK, SANDRA G (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:G
Last Name:BOTHWICK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-2147
Mailing Address - Country:US
Mailing Address - Phone:413-734-3154
Mailing Address - Fax:
Practice Address - Street 1:540 MEADOW STREET EXT
Practice Address - Street 2:SUITE 101
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2035
Practice Address - Country:US
Practice Address - Phone:413-789-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-14
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10298431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABOP23743Medicare ID - Type Unspecified