Provider Demographics
NPI:1841592284
Name:SANDBERG, MELISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SANDBERG
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 1:2445 LANE PARK RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9648
Mailing Address - Country:US
Mailing Address - Phone:244-658-2632
Mailing Address - Fax:
Practice Address - Street 1:2445 LANE PARK RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-9648
Practice Address - Country:US
Practice Address - Phone:224-465-8263
Practice Address - Fax:800-532-6989
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490132361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical