Provider Demographics
NPI:1699422006
Name:SANDERS, MARK ASHLEY (MED)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ASHLEY
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 S HORSESHOE BND
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-7013
Mailing Address - Country:US
Mailing Address - Phone:316-304-8482
Mailing Address - Fax:
Practice Address - Street 1:971 E WICHITA AVE
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-2444
Practice Address - Country:US
Practice Address - Phone:316-400-3535
Practice Address - Fax:316-400-3536
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician