1770712291 NPI number — MICHELLE AUDREY SANDERS CMHC

Table of content: MICHELLE AUDREY SANDERS CMHC (NPI 1770712291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770712291 NPI number — MICHELLE AUDREY SANDERS CMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDERS
Provider First Name:
MICHELLE
Provider Middle Name:
AUDREY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLENETSKI
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
AUDREY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770712291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1592 SPAULDING LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-2852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-217-5089
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5689 S REDWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 27
Provider Business Practice Location Address City Name:
TAYLORSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84123-5447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-266-2485
Provider Business Practice Location Address Fax Number:
866-644-9206
Provider Enumeration Date:
07/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7825382-6004 . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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