Provider Demographics
NPI:1710008305
Name:SANDAGE, SUSAN GAIL (LAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GAIL
Last Name:SANDAGE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W OLNEY RD
Mailing Address - Street 2:STE. D
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1864
Mailing Address - Country:US
Mailing Address - Phone:757-628-8182
Mailing Address - Fax:757-628-8288
Practice Address - Street 1:400 W OLNEY RD
Practice Address - Street 2:STE.D
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1864
Practice Address - Country:US
Practice Address - Phone:757-628-8182
Practice Address - Fax:757-628-8288
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000360171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist