Individual
DR. SANFORD LLOYD PEDERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D., HSPP
Contact information
Practice address
494 S EMERSON AVE, SUITE C, GREENWOOD, IN 46143-1912
(317) 889-3901
(317) 889-3902
Mailing address
570 PINE LAKE DR, GREENWOOD, IN 46143-7695
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
20041487A
IN
103T00000X
Psychologist
Primary
20041487A
IN
103TA0700X
Adult Development & Aging Psychologist
20041487A
IN
103TC0700X
Clinical Psychologist
20041487A
IN
103TF0200X
Forensic Psychologist
20041487A
IN
103TH0004X
Health Psychologist
20041487A
IN
103TH0100X
Health Service Psychologist
20041487A
IN
103TR0400X
Rehabilitation Psychologist
20041487A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200227370
—
IN
01
—
225420
MEDICATE PTAN
—
01
—
225420A
MEDICARE LEGACY ID
—
Enumeration date
05/20/2007
Last updated
08/02/2024
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