Provider Demographics
NPI:1487756110
Name:DEVINE, SANDRA WALSH (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:WALSH
Last Name:DEVINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:MARIE
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:530 ALAMEDA DEL PRADO
Mailing Address - Street 2:#326
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6027
Mailing Address - Country:US
Mailing Address - Phone:415-884-9003
Mailing Address - Fax:415-884-9003
Practice Address - Street 1:300 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE 322
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4334
Practice Address - Country:US
Practice Address - Phone:415-884-9003
Practice Address - Fax:415-884-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS115481041C0700X
CALCS 115481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS11548OtherBOARD OF BEHAV SCIENCE
R36985Medicare UPIN
ZZZ32627ZMedicare ID - Type Unspecified