Healthcare Provider Details

I. General information

NPI: 1477103315
Provider Name (Legal Business Name): TIA L SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 W BELOIT RD STE 201
MILWAUKEE WI
53227-4357
US

IV. Provider business mailing address

4113 N 100TH ST
MILWAUKEE WI
53222-1311
US

V. Phone/Fax

Practice location:
  • Phone: 414-499-5765
  • Fax:
Mailing address:
  • Phone: 414-499-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7097-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: