Provider Demographics
NPI:1669731790
Name:SANDERSON, DANIEL MARK (PHD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 N 300 W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2770
Mailing Address - Country:US
Mailing Address - Phone:435-862-8273
Mailing Address - Fax:435-275-4256
Practice Address - Street 1:166 N 300 W
Practice Address - Street 2:SUITE 1
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2770
Practice Address - Country:US
Practice Address - Phone:435-862-8273
Practice Address - Fax:435-275-4256
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT317584-2501103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent