Provider Demographics
NPI:1609933209
Name:PROCHAZKA, SANDRA G (LMSW)
Entity Type:Individual
Prefix:MR
First Name:SANDRA
Middle Name:G
Last Name:PROCHAZKA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 JENNINGS RD
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9511
Mailing Address - Country:US
Mailing Address - Phone:734-786-2364
Mailing Address - Fax:734-786-4915
Practice Address - Street 1:3830 PACKARD ST STE 250
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2273
Practice Address - Country:US
Practice Address - Phone:734-786-2364
Practice Address - Fax:734-786-4915
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010058221041C0700X
MI4101005601106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOMO1260Medicare ID - Type Unspecified