=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053863951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEON SANDERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2016
-----------------------------------------------------
Last Update Date | 01/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2915 CHILHOWEE DR
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-9443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-446-5445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3378 GREENBRIAR PKWY SW APT 9201
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-0620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-446-5445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | LPC012673
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | APC005267
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC012673
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LPC012673
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LPC012673
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------