Healthcare Provider Details

I. General information

NPI: 1467079046
Provider Name (Legal Business Name): DAVID RUSSELL SANDERS LPA, LSSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 NE LOOP 410 STE 101
SAN ANTONIO TX
78217-4840
US

IV. Provider business mailing address

2700 NE LOOP 410 STE 101
SAN ANTONIO TX
78217-4840
US

V. Phone/Fax

Practice location:
  • Phone: 210-362-5200
  • Fax:
Mailing address:
  • Phone: 210-362-5200
  • Fax: 866-332-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number15541
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6557
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: