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General NPI Number Information
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NPI Number | 1306685490
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Entity Type | Individual
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Provider Name | GREGORY AUSTIN SANDERS LAC
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Gender | Male
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Dates
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Enumeration Date | 05/20/2024
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | GILA RIVER HEALTH CENTER-RESIDENTIAL TREATMENT CENTER 3850 N. 16TH ST., E. BASELINE RD.
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City | LAVEEN
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State | AZ
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Zip | 85339
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Country | US
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Telephone | 520-796-3860
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Fax |
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Provider Business Mailing Address
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Address Line | GILA RIVER HEALTH CENTER-RESIDENTIAL TREATMENT CENTER 3850 N. 16TH ST., E. BASELINE RD.
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City | LAVEEN
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State | AZ
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Zip | 85339
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Country | US
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Telephone | 520-796-3860
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LAC-22722
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License Number State | AZ
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