Provider Demographics
NPI:1326194507
Name:SANDERS, PHYLLIS A (LCSW)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:A
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 WYNDHAM PARK DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5468
Mailing Address - Country:US
Mailing Address - Phone:770-808-4162
Mailing Address - Fax:404-320-6907
Practice Address - Street 1:1925 CENTURY BLVD NE
Practice Address - Street 2:SUITE 8
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3315
Practice Address - Country:US
Practice Address - Phone:404-320-6906
Practice Address - Fax:404-320-6907
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0003901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical