Provider Demographics
NPI:1023779071
Name:MATTHEWS, SANDRA VIRDA (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:VIRDA
Last Name:MATTHEWS
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 1:1393 ALLIGATOR DR
Mailing Address - Street 2:
Mailing Address - City:PANACEA
Mailing Address - State:FL
Mailing Address - Zip Code:32346-5113
Mailing Address - Country:US
Mailing Address - Phone:513-378-7000
Mailing Address - Fax:
Practice Address - Street 1:1393 ALLIGATOR DR
Practice Address - Street 2:
Practice Address - City:PANACEA
Practice Address - State:FL
Practice Address - Zip Code:32346-5113
Practice Address - Country:US
Practice Address - Phone:513-378-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP5342103TC0700X
FLPY10575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5342OtherFEE FOR SERVICE
FLPY10575OtherFEE FOR SERVICE