Provider Demographics
NPI:1205540648
Name:SANFORD, ALISA (LCSW)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:SANFORD
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 1:1109 COLQUITT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1921
Mailing Address - Country:US
Mailing Address - Phone:404-310-0752
Mailing Address - Fax:
Practice Address - Street 1:1924 CLAIRMONT RD STE 10
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3450
Practice Address - Country:US
Practice Address - Phone:404-913-2576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0076781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical