Provider Demographics
NPI:1316494362
Name:SANDER, ELISSA (OTR/L)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SANDER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21630 SE 257TH PL
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-7575
Mailing Address - Country:US
Mailing Address - Phone:317-847-7921
Mailing Address - Fax:
Practice Address - Street 1:33330 8TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6325
Practice Address - Country:US
Practice Address - Phone:253-945-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 60676493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT 60676493OtherOCCUPATIONAL THERAPY LICENSE