Provider Demographics
NPI:1033243951
Name:SANDER, JERRY (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:SANDER
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1618
Mailing Address - Country:US
Mailing Address - Phone:845-987-0094
Mailing Address - Fax:
Practice Address - Street 1:92 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1618
Practice Address - Country:US
Practice Address - Phone:845-986-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03511911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300075678OtherMEDICARE PTAN
NYN41981Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER