Healthcare Provider Details

I. General information

NPI: 1073143863
Provider Name (Legal Business Name): SANDERICA HUTTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 CUSTER AVE SE
ATLANTA GA
30316-3304
US

IV. Provider business mailing address

8701 WADFORD DR STE 100
RALEIGH NC
27616-9028
US

V. Phone/Fax

Practice location:
  • Phone: 248-220-7980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85998
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85998
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: