Provider Demographics
NPI:1396300844
Name:SANDERS, QIANA
Entity type:Individual
Prefix:
First Name:QIANA
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2597 PENSHURST WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7850
Mailing Address - Country:US
Mailing Address - Phone:757-309-3397
Mailing Address - Fax:
Practice Address - Street 1:5606 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:891-107-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-83754106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VARBT-19-83754OtherTRICARE