Provider Demographics
NPI:1366410144
Name:UNTIED, SANDRA L (RN, BSN, MSW, LISW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:UNTIED
Suffix:
Gender:F
Credentials:RN, BSN, MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6481 WELSH RD
Mailing Address - Street 2:
Mailing Address - City:NASHPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43830-9512
Mailing Address - Country:US
Mailing Address - Phone:740-454-9841
Mailing Address - Fax:
Practice Address - Street 1:2845 BELL ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1720
Practice Address - Country:US
Practice Address - Phone:740-454-9766
Practice Address - Fax:740-588-6452
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI74801041C0700X
OHRN100389163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH218931OtherTRICARE/MHN PIN
OH9071405OtherPRIVATE HLTHCARE SYS PIN
OH000000218890OtherANTHEM PIN
OH246101OtherMOUNT CARMEL PIN
OH7602165OtherAETNA PIN
OH2032248OtherCIGNA BH PIN
OHY555056OtherTHE HEALTH PLAN PIN
OH246101OtherMOUNT CARMEL PIN