Provider Demographics
NPI:1154867802
Name:SANDERS, CRYSTAL SHAWNA' (LLMSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHAWNA'
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14244 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2857
Mailing Address - Country:US
Mailing Address - Phone:313-574-8671
Mailing Address - Fax:
Practice Address - Street 1:33505 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1630
Practice Address - Country:US
Practice Address - Phone:734-721-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096490104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker