Healthcare Provider Details

I. General information

NPI: 1073594602
Provider Name (Legal Business Name): LISA M SANDERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 ROUTE 27 103
KENDALL PARK NJ
08824-1536
US

IV. Provider business mailing address

3250 STATE ROUTE 27 103
KENDALL PARK NJ
08824-1445
US

V. Phone/Fax

Practice location:
  • Phone: 908-507-6671
  • Fax: 732-951-2135
Mailing address:
  • Phone: 908-507-6671
  • Fax: 732-951-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05334000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: