Provider Demographics
NPI:1659385755
Name:SANDERS, MARILYN DENISE (LMSW, MACRO)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:DENISE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LMSW, MACRO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 NORTH PARK DRIVE 501
Mailing Address - Street 2:501
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-793-1217
Mailing Address - Fax:
Practice Address - Street 1:17336 W. 12 MILE ROAD
Practice Address - Street 2:103
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-796-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010595521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0898005OtherBLUE CROSS BLUE SHIELD/BLUE CARE NETWORK
MI562276OtherVALUE OPTIONS
MI0P15280OtherMEDICARE PART - B
MI600538229OtherMAGELLAN BEHAVIORAL HEALTH SERVICES
MI59557OtherHEALTH PLAN OF MICHIGAN, INC.
MI80-0-89-7195OtherBLUE CROSS BLUE SHIELD /BLUE CARE NETWORK
MI80-0-89-7195OtherBLUE CROSS BLUE SHIELD /BLUE CARE NETWORK
MIMI3531Medicare PIN