Healthcare Provider Details

I. General information

NPI: 1093575508
Provider Name (Legal Business Name): SCOUT SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 STACEY BURK DR
FLORA IL
62839-3241
US

IV. Provider business mailing address

708 SHADWELL AVE
FLORA IL
62839-2309
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-2131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149026492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: