Provider Demographics
NPI:1639246994
Name:SANDERSON, AMY L (LCSW-PIP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:LCSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S MAIN ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4136
Mailing Address - Country:US
Mailing Address - Phone:605-225-1010
Mailing Address - Fax:605-225-1017
Practice Address - Street 1:14 S MAIN ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4136
Practice Address - Country:US
Practice Address - Phone:605-225-1010
Practice Address - Fax:605-225-1017
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD32421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD101497Medicare PIN