Provider Demographics
NPI:1053784728
Name:SANDERS, STACY BERNARD (PHD, LAC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:BERNARD
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:898 BROOKS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:LA
Mailing Address - Zip Code:71268-4670
Mailing Address - Country:US
Mailing Address - Phone:915-276-2548
Mailing Address - Fax:
Practice Address - Street 1:206 E REYNOLDS DR STE G2
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2873
Practice Address - Country:US
Practice Address - Phone:915-276-2548
Practice Address - Fax:318-259-4571
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X, 171M00000X
LALAC-5154101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator