Provider Demographics
NPI:1902371982
Name:SANDERS, WANDA YOUNG (MED, EDS)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:YOUNG
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 LAMONT CIR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4528
Mailing Address - Country:US
Mailing Address - Phone:770-355-8217
Mailing Address - Fax:
Practice Address - Street 1:1230 LAMONT CIR
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4528
Practice Address - Country:US
Practice Address - Phone:770-355-8217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA234989103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty