Provider Demographics
NPI:1346981008
Name:SANDLASS, NICOLE RAE (CASAC-T)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:SANDLASS
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WHITESBORO ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3015
Mailing Address - Country:US
Mailing Address - Phone:315-724-5168
Mailing Address - Fax:
Practice Address - Street 1:500 WHITESBORO ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3015
Practice Address - Country:US
Practice Address - Phone:315-724-5168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32336101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY271578278Medicaid