Provider Demographics
NPI:1881673317
Name:SANDUSKY, PATRICIA M (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:SANDUSKY
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 8068
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-8068
Mailing Address - Country:US
Mailing Address - Phone:601-693-8307
Mailing Address - Fax:601-693-6794
Practice Address - Street 1:5004 HIGHWAY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1021
Practice Address - Country:US
Practice Address - Phone:601-693-8307
Practice Address - Fax:601-693-6794
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33547103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S24118Medicare UPIN
MS680000173Medicare PIN