Provider Demographics
NPI:1821668591
Name:EMMANOUILIDES, SANDRA MADELINE (LSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MADELINE
Last Name:EMMANOUILIDES
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MADELINE
Other - Last Name:ENCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 S. ORANGE ST. STE 5
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:855-687-2410
Mailing Address - Fax:855-687-2410
Practice Address - Street 1:300 W. BALTIMORE AVE.
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:855-687-2410
Practice Address - Fax:855-687-2410
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1379991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical