Provider Demographics
NPI:1760561500
Name:SANDERS, LYNN M (MA)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 284
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-9121
Mailing Address - Country:US
Mailing Address - Phone:304-673-1913
Mailing Address - Fax:304-466-1676
Practice Address - Street 1:HC 74 BOX 284
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-9121
Practice Address - Country:US
Practice Address - Phone:304-673-1913
Practice Address - Fax:304-466-1676
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000778Medicaid