Provider Demographics
NPI:1215369343
Name:SANDERS, IVAN THOMAS (LMSW)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:THOMAS
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4232
Mailing Address - Country:US
Mailing Address - Phone:803-775-5080
Mailing Address - Fax:803-773-6256
Practice Address - Street 1:115 N HARVIN ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4956
Practice Address - Country:US
Practice Address - Phone:803-778-2835
Practice Address - Fax:803-778-4017
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
SC104171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)