Provider Demographics
NPI:1659423721
Name:STADER, SANDRA R (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:R
Last Name:STADER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:
Practice Address - Street 1:1800 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6827
Practice Address - Country:US
Practice Address - Phone:803-898-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC621103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0302Medicaid
SCS878796719Medicare PIN
SCPS0302Medicaid