Provider Demographics
NPI:1932797412
Name:DEATLEY, SANDRA SUE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
Last Name:DEATLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:SUE
Other - Last Name:MCHUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2328 NE 37TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-2503
Mailing Address - Country:US
Mailing Address - Phone:816-531-4285
Mailing Address - Fax:
Practice Address - Street 1:2328 NE 37TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-2503
Practice Address - Country:US
Practice Address - Phone:816-531-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190283351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019028335OtherMISSOURI CLINICAL SOCIAL WORKER LICENSE