Healthcare Provider Details

I. General information

NPI: 1174776447
Provider Name (Legal Business Name): TIFFANY DEVICA SANDERS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 ENTERPRISE DR 2515
WESTCHESTER IL
60154-5814
US

IV. Provider business mailing address

1405 N HARLEM AVE B
OAK PARK IL
60302-1257
US

V. Phone/Fax

Practice location:
  • Phone: 708-223-8405
  • Fax:
Mailing address:
  • Phone: 708-223-8405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-007847
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number235591
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: