Provider Demographics
NPI:1154811933
Name:SANDERS, NICOLAS TYRELL (LSW)
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:TYRELL
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11659 E 25TH DR UNIT 3306
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80010-1392
Mailing Address - Country:US
Mailing Address - Phone:504-351-6256
Mailing Address - Fax:
Practice Address - Street 1:11659 E 25TH DR UNIT 3306
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-1392
Practice Address - Country:US
Practice Address - Phone:504-351-6256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099303491041C0700X
LA14451104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical