Provider Demographics
NPI:1922364744
Name:SILVA, SANDRA M (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:SILVA
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 1:471 SE DALVA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4717
Mailing Address - Country:US
Mailing Address - Phone:772-626-6827
Mailing Address - Fax:772-220-3484
Practice Address - Street 1:3577 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8153
Practice Address - Country:US
Practice Address - Phone:772-220-3439
Practice Address - Fax:772-220-3484
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X, 222Q00000X
FL157451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1922364744Medicaid
FLPENDINGMedicaid