Provider Demographics
NPI:1255899761
Name:SANDERS, SAMANTHA ALYSE (LMFT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ALYSE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7652 YORKTOWN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9458
Mailing Address - Country:US
Mailing Address - Phone:269-967-8875
Mailing Address - Fax:
Practice Address - Street 1:1611 W CENTRE AVE STE 201
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5393
Practice Address - Country:US
Practice Address - Phone:269-281-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101007277106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty