Provider Demographics
NPI:1346508728
Name:WIXTED, SANDRA ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANN
Last Name:WIXTED
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 1:323 TAPPAN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5334
Mailing Address - Country:US
Mailing Address - Phone:617-738-0179
Mailing Address - Fax:
Practice Address - Street 1:323 TAPPAN ST APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-5334
Practice Address - Country:US
Practice Address - Phone:617-738-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1041221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA104122Medicaid