Healthcare Provider Details

I. General information

NPI: 1568978963
Provider Name (Legal Business Name): EDWARD MICHAEL SANDERS CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 STATE ST
SANTA BARBARA CA
93110-1848
US

IV. Provider business mailing address

228 W ORTEGA ST APT B
SANTA BARBARA CA
93101-5567
US

V. Phone/Fax

Practice location:
  • Phone: 805-964-4795
  • Fax:
Mailing address:
  • Phone: 805-259-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1764831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: