Provider Demographics
NPI:1689492126
Name:SANDERS, RAQUEL SHONTA
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:SHONTA
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 1:3019 N PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8016
Mailing Address - Country:US
Mailing Address - Phone:815-975-3330
Mailing Address - Fax:779-423-1761
Practice Address - Street 1:3019 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8016
Practice Address - Country:US
Practice Address - Phone:815-975-3330
Practice Address - Fax:779-423-1761
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112597104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker