Provider Demographics
NPI:1750782389
Name:FERRELL, SANDRA (MA, LP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:FERRELL
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2909
Mailing Address - Country:US
Mailing Address - Phone:507-437-9085
Mailing Address - Fax:507-437-2393
Practice Address - Street 1:203 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2909
Practice Address - Country:US
Practice Address - Phone:507-437-9085
Practice Address - Fax:507-437-2393
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0498103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN385734401Medicaid
MN385734400Medicaid