=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275269227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY C SANDERS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2022
-----------------------------------------------------
Last Update Date | 07/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2553 BRAINTREE DR
-----------------------------------------------------
City | HIGH RIDGE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63049-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-660-0769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 FENTON PLZ UNIT 9
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-9991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-660-0769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225C00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Counselor
-----------------------------------------------------
License Number | 00250723
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2020009675
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------