Provider Demographics
NPI:1932297181
Name:SANDROCK, LETITIA S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LETITIA
Middle Name:S
Last Name:SANDROCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64A WHITE ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1635
Mailing Address - Country:US
Mailing Address - Phone:732-778-5652
Mailing Address - Fax:866-293-7693
Practice Address - Street 1:64A WHITE ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1635
Practice Address - Country:US
Practice Address - Phone:732-778-5652
Practice Address - Fax:866-293-7693
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4108103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-2630850OtherFEDERAL EIN