Provider Demographics
NPI:1043622798
Name:SANDOCK, SUSAN GAIL (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAIL
Last Name:SANDOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 E JEFFERSON BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3117
Mailing Address - Country:US
Mailing Address - Phone:574-287-4197
Mailing Address - Fax:
Practice Address - Street 1:919 E JEFFERSON BLVD STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3117
Practice Address - Country:US
Practice Address - Phone:574-287-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004026A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical