Provider Demographics
NPI:1558824649
Name:SANFORD, MICHELLE (RBT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2329
Mailing Address - Country:US
Mailing Address - Phone:803-381-3309
Mailing Address - Fax:
Practice Address - Street 1:215 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-3260
Practice Address - Country:US
Practice Address - Phone:334-208-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-19-82902106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty