Provider Demographics
NPI:1447349386
Name:MOEHLE, SANDRA LEE (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MOEHLE
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:PO BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVENUE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPARTMENT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3310
Practice Address - Country:US
Practice Address - Phone:860-545-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTA-3648-SASCC101YA0400X
CT0045351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800002795Medicare PIN