Provider Demographics
NPI:1922102003
Name:SANDERS, ERIC LEROY (BCC, LADC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LEROY
Last Name:SANDERS
Suffix:
Gender:M
Credentials:BCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ROSEDALE RD NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1933
Mailing Address - Country:US
Mailing Address - Phone:763-236-4569
Mailing Address - Fax:763-236-4370
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-4569
Practice Address - Fax:763-236-4370
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301705101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)