Provider Demographics
NPI:1285886374
Name:SANDERS, ELISSA (NCC, LPC)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MARGARET MITCHELL DR NW APT 35
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1700
Mailing Address - Country:US
Mailing Address - Phone:404-351-9445
Mailing Address - Fax:404-826-1626
Practice Address - Street 1:3050 MARGARET MITCHELL DR NW
Practice Address - Street 2:APT. 35
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1721
Practice Address - Country:US
Practice Address - Phone:404-351-9445
Practice Address - Fax:404-826-1626
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA170428375BMedicaid
11878515OtherCAQH PROVIDER ID
424748OtherMHN PROVIDER ID