Provider Demographics
NPI:1952637068
Name:NETTLES, SANDRA GAIL (LCSW, MSSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:GAIL
Last Name:NETTLES
Suffix:
Gender:F
Credentials:LCSW, MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 W DUNLAP AVE
Mailing Address - Street 2:206
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2844
Mailing Address - Country:US
Mailing Address - Phone:602-750-8051
Mailing Address - Fax:602-674-5701
Practice Address - Street 1:2301 W DUNLAP AVE
Practice Address - Street 2:206
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2844
Practice Address - Country:US
Practice Address - Phone:602-750-8051
Practice Address - Fax:602-674-5701
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-107821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical