Provider Demographics
NPI:1508486572
Name:SANDSTROM, MARLENE (PHD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GALE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01267-2806
Mailing Address - Country:US
Mailing Address - Phone:413-884-5300
Mailing Address - Fax:
Practice Address - Street 1:11 GALE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2806
Practice Address - Country:US
Practice Address - Phone:413-884-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical