Provider Demographics
NPI:1447713227
Name:SANDOR, GABRIELLE NATASHA (LCAS-A)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:NATASHA
Last Name:SANDOR
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 COVENTRY WOODS CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3769
Mailing Address - Country:US
Mailing Address - Phone:336-501-4065
Mailing Address - Fax:
Practice Address - Street 1:326 N SPRING ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2722
Practice Address - Country:US
Practice Address - Phone:336-631-1948
Practice Address - Fax:336-631-1948
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24757101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLCAS-24757OtherNCSAPPB