Provider Demographics
NPI:1942571435
Name:TYSAR-GILBERT, SANDRA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIE
Last Name:TYSAR-GILBERT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27941 HARPER AVE STE 103
Mailing Address - Street 2:MAILBOX # 5
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1535
Mailing Address - Country:US
Mailing Address - Phone:249-229-4778
Mailing Address - Fax:
Practice Address - Street 1:27941 HARPER AVENUE, STE 103
Practice Address - Street 2:MAILBOX # 5
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-4808
Practice Address - Country:US
Practice Address - Phone:249-229-4778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010931171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty