Provider Demographics
NPI:1164094157
Name:SANDERS, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 W COMMERCE ST # 4164
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:539 W COMMERCE ST # 4164
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-1953
Practice Address - Country:US
Practice Address - Phone:940-782-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-11
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5770103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty