Provider Demographics
NPI:1851375802
Name:SANDBERG, GENELL G (PHD)
Entity Type:Individual
Prefix:
First Name:GENELL
Middle Name:G
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 APACHE CT
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1504
Mailing Address - Country:US
Mailing Address - Phone:712-239-1111
Mailing Address - Fax:712-239-1199
Practice Address - Street 1:2601 APACHE CT
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1504
Practice Address - Country:US
Practice Address - Phone:712-239-1111
Practice Address - Fax:712-239-1199
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00562103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W02735Medicare UPIN
IA10889Medicare ID - Type Unspecified