Provider Demographics
NPI:1053778837
Name:SANDBERG, TAYLOR VICTORIA
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:VICTORIA
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S 4TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4777
Mailing Address - Country:US
Mailing Address - Phone:701-775-7725
Mailing Address - Fax:701-775-7880
Practice Address - Street 1:212 S 4TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4777
Practice Address - Country:US
Practice Address - Phone:701-775-7725
Practice Address - Fax:701-775-7880
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5243104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker