Provider Demographics
NPI:1982710448
Name:WOLOSENKO, SANDRA L (LICSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:WOLOSENKO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1329
Mailing Address - Country:US
Mailing Address - Phone:413-586-9461
Mailing Address - Fax:413-584-8671
Practice Address - Street 1:151 MYSTIC AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4632
Practice Address - Country:US
Practice Address - Phone:781-396-1199
Practice Address - Fax:781-396-1439
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101971104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAR41982Medicare UPIN
MAP02500Medicare ID - Type Unspecified