Healthcare Provider Details

I. General information

NPI: 1295342350
Provider Name (Legal Business Name): KOLTON SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N HUDSON ST
ALTUS OK
73521-3811
US

IV. Provider business mailing address

1420 SAVANNAH CIR
ALTUS OK
73521-1227
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-2452
  • Fax:
Mailing address:
  • Phone: 580-647-6247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: