Provider Demographics
NPI:1659589885
Name:PEDERSON, SANFORD LLOYD (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:LLOYD
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 S EMERSON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1912
Mailing Address - Country:US
Mailing Address - Phone:317-889-3901
Mailing Address - Fax:317-889-3902
Practice Address - Street 1:494 S EMERSON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1912
Practice Address - Country:US
Practice Address - Phone:317-889-3901
Practice Address - Fax:317-889-3902
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041487103G00000X, 103T00000X, 103TA0700X, 103TC0700X, 103TF0200X, 103TH0004X, 103TH0100X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
225420OtherMEDICATE PTAN
225420AOtherMEDICARE LEGACY ID
IN200227370Medicaid
225420AOtherMEDICARE LEGACY ID