Provider Demographics
NPI:1992905459
Name:SANDERSON, DIANA SUE (LCSW)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:SUE
Last Name:SANDERSON
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 1:67 ALBERT BLOOD RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04849-5033
Mailing Address - Country:US
Mailing Address - Phone:207-763-3964
Mailing Address - Fax:207-763-3967
Practice Address - Street 1:67 ALBERT BLOOD RD
Practice Address - Street 2:
Practice Address - City:LINCOLNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04849-5033
Practice Address - Country:US
Practice Address - Phone:207-763-3964
Practice Address - Fax:207-763-3967
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC110191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical