Provider Demographics
NPI:1245637107
Name:DETTRA, SANDRA L (BSW CSAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:DETTRA
Suffix:
Gender:F
Credentials:BSW CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15D LOUDOUN ST SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-2908
Mailing Address - Country:US
Mailing Address - Phone:703-362-6682
Mailing Address - Fax:
Practice Address - Street 1:15D LOUDOUN ST SW
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-2908
Practice Address - Country:US
Practice Address - Phone:703-362-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710000797101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)