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General NPI Number Information
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NPI Number | 1487717963
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Entity Type | Individual
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Provider Name | SUSAN L SANDERSON PH.D
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Gender | Female
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 7400 HIGHWAY N
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City | O FALLON
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State | MO
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Zip | 63368-7013
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Country | US
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Telephone | 636-561-7080
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Fax | 636-561-0463
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Provider Business Mailing Address
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Address Line | 311 NAUTICA LN
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City | LAKE ST LOUIS
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State | MO
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Zip | 63367-2658
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Country | US
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Telephone | 636-561-1788
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Fax | 636-561-0463
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2000166718
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License Number State | MO
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