Provider Demographics
NPI:1962013516
Name:SANDERSON, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-2516
Mailing Address - Country:US
Mailing Address - Phone:718-300-1414
Mailing Address - Fax:
Practice Address - Street 1:242 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-2516
Practice Address - Country:US
Practice Address - Phone:718-300-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY693464252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY419585101OtherSTUDENT WITH DISABILITIES CERTIFICATION
NY734110458OtherDRIVERS LICENSE