Provider Demographics
NPI:1699212431
Name:SANDERSON PSYCHOLOGICAL, LLC
Entity Type:Organization
Organization Name:SANDERSON PSYCHOLOGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:412-370-4848
Mailing Address - Street 1:95 ENTERPRISE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELIZABETH
Mailing Address - State:PA
Mailing Address - Zip Code:15037-2070
Mailing Address - Country:US
Mailing Address - Phone:412-370-4848
Mailing Address - Fax:412-754-2006
Practice Address - Street 1:95 ENTERPRISE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:ELIZABETH
Practice Address - State:PA
Practice Address - Zip Code:15037-2070
Practice Address - Country:US
Practice Address - Phone:412-370-4848
Practice Address - Fax:412-754-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018190251S00000X
PAPC006524251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1871842591OtherNPI INDIVIDUAL