Provider Demographics
NPI:1962386854
Name:SANDERS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30845 RUNNING STRM APT 22
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1281
Mailing Address - Country:US
Mailing Address - Phone:248-421-8668
Mailing Address - Fax:313-397-7708
Practice Address - Street 1:14848 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2646
Practice Address - Country:US
Practice Address - Phone:248-421-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820418004261QM0801X, 3104A0625X, 315P00000X, 3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities