Provider Demographics
NPI:1750592903
Name:SANDRA D. STREET MA, LPC
Entity type:Organization
Organization Name:SANDRA D. STREET MA, LPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:304-242-2817
Mailing Address - Street 1:PO BOX 6101
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-0736
Mailing Address - Country:US
Mailing Address - Phone:304-242-2817
Mailing Address - Fax:304-242-5161
Practice Address - Street 1:40 12TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3279
Practice Address - Country:US
Practice Address - Phone:304-242-2817
Practice Address - Fax:304-242-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-26
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10053101YA0400X
OHC0004992101YP2500X
WV37956101YP2500X
WV1135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W43745Medicare UPIN