Healthcare Provider Details

I. General information

NPI: 1447584511
Provider Name (Legal Business Name): DR. LIZA SANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 W 200 S STE 2E
KAMAS UT
84036-9010
US

IV. Provider business mailing address

596 ASH CT
KAMAS UT
84036-9275
US

V. Phone/Fax

Practice location:
  • Phone: 801-360-6955
  • Fax:
Mailing address:
  • Phone: 435-640-3138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number435
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number435
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1149
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number435
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number435
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number435
License Number StateWY
# 7
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number435
License Number StateWY
# 8
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number435
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: