Healthcare Provider Details

I. General information

NPI: 1396536132
Provider Name (Legal Business Name): GAVIN DEREK SANDERS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 LYNDON B JOHNSON FWY STE B555
DALLAS TX
75243-1166
US

IV. Provider business mailing address

3796 VITRUVIAN WAY
ADDISON TX
75001-4000
US

V. Phone/Fax

Practice location:
  • Phone: 888-606-0086
  • Fax: 346-223-0296
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number40538
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: