Healthcare Provider Details

I. General information

NPI: 1306285549
Provider Name (Legal Business Name): LAVINA LEANNE SANDERS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAVINA LEANNE CAVASOS PH.D.

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-4210
US

IV. Provider business mailing address

2619 BAR HARBOR DR
FORT COLLINS CO
80524-2607
US

V. Phone/Fax

Practice location:
  • Phone: 720-591-2136
  • Fax:
Mailing address:
  • Phone: 505-328-0853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY.0004785
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: