MEDICARE: DR. KELLEY CHRISTINE SANDERS PH.D., CAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	CAP2880	FL
2	103TC0700X	Clinical Psychologist	PY8870	FL

General Provider Information

NPI Number	:	1366788606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEY CHRISTINE SANDERS PH.D., CAP

Provider Business Mailing Address
First Line	:	2023 TATUM AVENUE
Second Line	:	BUILDGING H, ROOM #110A
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214
Country	:	US
Telephone Number	:	904-546-6302
Fax Number	:

Provider Business Practice Location Address
First Line	:	2023 TATUM AVENUE
Second Line	:	BUILDGING H, ROOM #110A
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214
Country	:	US
Telephone Number	:	904-546-6302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2012
Last Update Date	:	02/02/2025

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