Provider Demographics
NPI:1467429126
Name:SANDERS, BUDDY D (MA)
Entity Type:Individual
Prefix:MRS
First Name:BUDDY
Middle Name:D
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:BUDDY
Other - Middle Name:D
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CAC, LCC
Mailing Address - Street 1:P. O. BOX 212401
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30917-2401
Mailing Address - Country:US
Mailing Address - Phone:706-869-0071
Mailing Address - Fax:706-869-0063
Practice Address - Street 1:119 DAVIS ROAD
Practice Address - Street 2:SUITE 1- B
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0200
Practice Address - Country:US
Practice Address - Phone:706-869-0071
Practice Address - Fax:706-869-0063
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA06040351101Y00000X
101YA0400X, 101YP1600X
GA171M00000X
GATG-BFTS-9712171W00000X
GAPD--BFTS-9965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA520070811AMedicaid