Provider Demographics
NPI:1912760604
Name:SANDERS, JOLIE (MED, ITDS)
Entity Type:Individual
Prefix:
First Name:JOLIE
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:MED, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3231
Mailing Address - Country:US
Mailing Address - Phone:321-213-1413
Mailing Address - Fax:
Practice Address - Street 1:400 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-3231
Practice Address - Country:US
Practice Address - Phone:321-213-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist