Healthcare Provider Details

I. General information

NPI: 1245066638
Provider Name (Legal Business Name): MICHAEL SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MILTON ST STE 6
DEDHAM MA
02026-2991
US

IV. Provider business mailing address

16 MILTON ST STE 6
DEDHAM MA
02026-2991
US

V. Phone/Fax

Practice location:
  • Phone: 888-955-1167
  • Fax: 888-245-9392
Mailing address:
  • Phone: 888-955-1167
  • Fax: 888-245-9392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: