Provider Demographics
NPI:1184789521
Name:SANDERSON, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 ALBERT BLOOD RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04849-5033
Mailing Address - Country:US
Mailing Address - Phone:207-763-3964
Mailing Address - Fax:
Practice Address - Street 1:143 HIGH ST
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6548
Practice Address - Country:US
Practice Address - Phone:207-338-3865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM2884Medicare ID - Type UnspecifiedPSYCHOLOGIST