Provider Demographics
NPI:1568541324
Name:MORO, SANDRA (LICSW,BC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MORO
Suffix:
Gender:F
Credentials:LICSW,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-3968
Mailing Address - Country:US
Mailing Address - Phone:413-540-1155
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:WELD BLDG
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-421-0060
Practice Address - Fax:401-421-6676
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN181049364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
Provider Identifiers
StateIdentifier IDID TypeIssuer
P37112Medicare UPIN
899004698Medicare ID - Type Unspecified