Provider Demographics
NPI:1639695380
Name:SANDRAS-GAUT, COURTNI BROOKE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:COURTNI
Middle Name:BROOKE
Last Name:SANDRAS-GAUT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24003-0541
Mailing Address - Country:US
Mailing Address - Phone:540-400-7431
Mailing Address - Fax:540-400-7091
Practice Address - Street 1:402 CAMPBELL AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-3627
Practice Address - Country:US
Practice Address - Phone:540-400-7431
Practice Address - Fax:540-400-7091
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040100611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical