Provider Demographics
NPI:1104523497
Name:SANDS, MAKENNA GRAYSON
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:GRAYSON
Last Name:SANDS
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 1:400 ROANOKE ST
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-3139
Mailing Address - Country:US
Mailing Address - Phone:434-363-3149
Mailing Address - Fax:
Practice Address - Street 1:400 ROANOKE ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-3139
Practice Address - Country:US
Practice Address - Phone:540-381-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014291101Y00000X
VA07040142101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor