Provider Demographics
NPI:1730739913
Name:SANDERS, SUSAN KELLY
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KELLY
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 1:2565 SEVEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37146-9109
Mailing Address - Country:US
Mailing Address - Phone:615-746-3500
Mailing Address - Fax:
Practice Address - Street 1:606B N MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37015-1312
Practice Address - Country:US
Practice Address - Phone:615-246-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRCR000000484173C00000X
TNMT0000002682225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty