Basic Information
| Provider Information | |||||||||
| NPI: | 1932379898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG. 9920B, MADIGAN ANNEX | ||||||||
| Address2: | |||||||||
| City: | JBLM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539686442 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539686442 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 10012 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 23424 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1932379898 | 01 | NPI | OTHER |