Provider Demographics
NPI:1568654168
Name:SANFORD, FELICIA L (PSYD, HSPP)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:L
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 ALANA DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1766
Mailing Address - Country:US
Mailing Address - Phone:815-462-3827
Mailing Address - Fax:815-462-3837
Practice Address - Street 1:339 ALANA DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1766
Practice Address - Country:US
Practice Address - Phone:815-462-3827
Practice Address - Fax:815-462-3837
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200424A103TC0700X
IL071006987103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932429OtherBLUE CROSS BLUE SHIELD
IN200991950Medicaid
IN000000659707OtherANTHEM
IN000000659707OtherANTHEM