Basic Information
| Provider Information | |||||||||
| NPI: | 1578795100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | PEARL | ||||||||
| MiddleName: | RHONNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDERSON | ||||||||
| OtherFirstName: | P. | ||||||||
| OtherMiddleName: | RHONNE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4704 PINE RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761234638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177293034 | ||||||||
| FaxNumber: | 8172634337 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | SUITE 602 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177293034 | ||||||||
| FaxNumber: | 8177354688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2009 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 005045-005671 | TX | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MT 681 | FL | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 005045-005671 | 01 | TX | BOARD OF MARRIAGE AND FAMILY THERAPY | OTHER | MT 681 | 01 | FL | BOARD OF CLINICAL SOCIAL WORK, MARRIAGE & FAMILY THERAPY, AND MENTAL HEALTH COUN | OTHER |