Provider Demographics
NPI:1043683535
Name:SANDERS, GWEN
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:SANDERS
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 1:114 EXCHANGE PL
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2510
Mailing Address - Country:US
Mailing Address - Phone:337-234-5715
Mailing Address - Fax:337-234-4466
Practice Address - Street 1:114 EXCHANGE PL
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2510
Practice Address - Country:US
Practice Address - Phone:337-234-5715
Practice Address - Fax:337-234-4466
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA129101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor