Provider Demographics
NPI:1114090099
Name:SANDEFORD, GERALD HILL (LPC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:HILL
Last Name:SANDEFORD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 331
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5337
Mailing Address - Country:US
Mailing Address - Phone:719-330-7665
Mailing Address - Fax:719-559-1130
Practice Address - Street 1:2790 N ACADEMY BLVD
Practice Address - Street 2:SUITE 331
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5337
Practice Address - Country:US
Practice Address - Phone:719-330-7665
Practice Address - Fax:719-559-1130
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3433101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO082741Medicaid