Provider Demographics
NPI:1518670009
Name:SANDERS, SERENA DAWN (MS)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:DAWN
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 GEORGIA WAY
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:TX
Mailing Address - Zip Code:77360-6787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:237 GEORGIA WAY
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:TX
Practice Address - Zip Code:77360-6787
Practice Address - Country:US
Practice Address - Phone:360-710-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123456103TC0700X
TXNA103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical