Provider Demographics
NPI:1457858342
Name:BAILEY, SANDRA J
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 FINDLAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4148
Mailing Address - Country:US
Mailing Address - Phone:740-354-3829
Mailing Address - Fax:
Practice Address - Street 1:508 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-8002
Practice Address - Country:US
Practice Address - Phone:937-544-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165998101YA0400X
OHQMHS101YM0800X
OHLCDCII.161621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0274897Medicaid