Provider Demographics
NPI:1861885907
Name:SANDERS, CHARLES (MS BCBA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3636
Mailing Address - Country:US
Mailing Address - Phone:708-307-1472
Mailing Address - Fax:
Practice Address - Street 1:3424 GROVE AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3636
Practice Address - Country:US
Practice Address - Phone:708-307-1472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103TB0200X
1-19-38715103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral