Healthcare Provider Details

I. General information

NPI: 1487717963
Provider Name (Legal Business Name): SUSAN L SANDERSON PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 HIGHWAY N
O FALLON MO
63368-7013
US

IV. Provider business mailing address

311 NAUTICA LN
LAKE ST LOUIS MO
63367-2658
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-7080
  • Fax: 636-561-0463
Mailing address:
  • Phone: 636-561-1788
  • Fax: 636-561-0463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2000166718
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: