Basic Information
| Provider Information | |||||||||
| NPI: | 1912368085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | TALOR | ||||||||
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| Credential: | PCC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2837 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403025594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | 7405321715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0900459-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0217612 | 05 | OH | MEDICAID |