Provider Demographics
NPI:1184223174
Name:SANDER, MALLORY ROSE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ROSE
Last Name:SANDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 COUNTRY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2253
Mailing Address - Country:US
Mailing Address - Phone:860-999-3223
Mailing Address - Fax:
Practice Address - Street 1:90 CARANDO DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-4205
Practice Address - Country:US
Practice Address - Phone:978-696-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician