Provider Demographics
NPI:1770712291
Name:SANDERS, MICHELLE AUDREY (CMHC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AUDREY
Last Name:SANDERS
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:AUDREY
Other - Last Name:GLENETSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1592 SPAULDING LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2852
Mailing Address - Country:US
Mailing Address - Phone:608-217-5089
Mailing Address - Fax:
Practice Address - Street 1:5689 S REDWOOD RD
Practice Address - Street 2:SUITE 27
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5447
Practice Address - Country:US
Practice Address - Phone:801-266-2485
Practice Address - Fax:866-644-9206
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7825382-6004OtherPROFESSIONAL LICENSE