Provider Demographics
NPI:1114007382
Name:SANDAS, ILYNE (MALP)
Entity Type:Individual
Prefix:MRS
First Name:ILYNE
Middle Name:
Last Name:SANDAS
Suffix:
Gender:F
Credentials:MALP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8141 MAPLEWOOD TER
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9661
Mailing Address - Country:US
Mailing Address - Phone:952-941-2889
Mailing Address - Fax:952-401-9326
Practice Address - Street 1:9531 W 78TH ST
Practice Address - Street 2:125
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3810
Practice Address - Country:US
Practice Address - Phone:952-941-2889
Practice Address - Fax:952-402-9326
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22G21SAOtherBLUE CROSS BLUE SHIELD OF
MN62-90595OtherMEDICA
FM1045950000Medicaid
MN937020OtherPREFERRED ONE
MN81860OtherHEALTH PARTNERS