Provider Demographics
NPI:1639929722
Name:HARRIS, SANDRA R (LMSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:HARRIS
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 1:115 LEGENDARY DR UNIT 204
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3748
Mailing Address - Country:US
Mailing Address - Phone:631-488-8482
Mailing Address - Fax:
Practice Address - Street 1:115 LEGENDARY DR UNIT 204
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3748
Practice Address - Country:US
Practice Address - Phone:631-488-8482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW19555104100000X
NY110212104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker