Provider Demographics
NPI:1548245889
Name:SANDERS, CHARLES W (PHD, EDS,MA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PHD, EDS,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 N TACOMA AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3512
Mailing Address - Country:US
Mailing Address - Phone:317-257-7434
Mailing Address - Fax:317-221-7733
Practice Address - Street 1:5555 N TACOMA AVE
Practice Address - Street 2:STE 204
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3512
Practice Address - Country:US
Practice Address - Phone:317-257-7434
Practice Address - Fax:317-221-7733
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002652A101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100381890Medicaid
IN100381890Medicaid