Healthcare Provider Details

I. General information

NPI: 1538985437
Provider Name (Legal Business Name): RAYANNE PHELPS SANDERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 JOHN KING RD
CRESTVIEW FL
32539-8306
US

IV. Provider business mailing address

1523 KAIS ST
BAKER FL
32531-8483
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-6020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW22609
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: