Provider Demographics
NPI:1306685490
Name:SANDERS, GREGORY AUSTIN (LAC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:AUSTIN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GILA RIVER HEALTH CENTER-RESIDENTIAL TREATMENT CENTER
Mailing Address - Street 2:3850 N. 16TH ST., E. BASELINE RD.
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339
Mailing Address - Country:US
Mailing Address - Phone:520-796-3860
Mailing Address - Fax:
Practice Address - Street 1:GILA RIVER HEALTH CENTER-RESIDENTIAL TREATMENT CENTER
Practice Address - Street 2:3850 N. 16TH ST., E. BASELINE RD.
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339
Practice Address - Country:US
Practice Address - Phone:520-796-3860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health