Provider Demographics
NPI:1528350535
Name:SANDISON, CHARLES DAVID
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:SANDISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-262-0937
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-262-0937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS532115135684171W00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171W00000XOther Service ProvidersContractor