Provider Demographics
NPI:1205935350
Name:BECKER-WARDEN, SANDRA JO (LCSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:JO
Last Name:BECKER-WARDEN
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 1:2014 VANDALIA
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234
Mailing Address - Country:US
Mailing Address - Phone:618-345-9587
Mailing Address - Fax:618-345-9536
Practice Address - Street 1:2014 VANDALIA
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234
Practice Address - Country:US
Practice Address - Phone:618-345-9587
Practice Address - Fax:618-345-9536
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW001839103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK13396Medicare ID - Type Unspecified
L21892Medicare UPIN