Provider Demographics
NPI:1457393563
Name:SANDERSON, PAUL D (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FOXBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FOXBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:02035-2438
Practice Address - Country:US
Practice Address - Phone:508-543-7160
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2089103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02319Medicare ID - Type Unspecified