Provider Demographics
NPI:1154840338
Name:SANDERSON, DAVID EUGENE (LADC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EUGENE
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-0206
Mailing Address - Country:US
Mailing Address - Phone:218-631-3610
Mailing Address - Fax:218-631-3917
Practice Address - Street 1:12214 200TH ST
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-3124
Practice Address - Country:US
Practice Address - Phone:218-631-3610
Practice Address - Fax:218-631-3917
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302384101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)