Provider Demographics
NPI:1053828137
Name:SANDERS, KEVIN EZELL (LLPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EZELL
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 E MADGE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-2172
Mailing Address - Country:US
Mailing Address - Phone:313-424-0101
Mailing Address - Fax:
Practice Address - Street 1:1410 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0046
Practice Address - Country:US
Practice Address - Phone:248-456-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health