Provider Demographics
NPI:1447584511
Name:SANDERSON, LIZA
Entity Type:Individual
Prefix:DR
First Name:LIZA
Middle Name:
Last Name:SANDERSON
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 1:596 ASH CT
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-9275
Mailing Address - Country:US
Mailing Address - Phone:435-640-3138
Mailing Address - Fax:
Practice Address - Street 1:228 W 200 S STE 2E
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-9010
Practice Address - Country:US
Practice Address - Phone:801-360-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY435101Y00000X, 101YM0800X, 101YS0200X, 103TS0200X, 251B00000X, 251C00000X, 101YP2500X
WY1149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY128433900Medicaid