Basic Information
| Provider Information | |||||||||
| NPI: | 1386778751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CORENNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MFT INTERN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCALES | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | CORENNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4240 LOST HILLS RD UNIT 1805 | ||||||||
| Address2: | |||||||||
| City: | AGOURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913015379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188781565 | ||||||||
| FaxNumber: | 8188781565 | ||||||||
| Practice Location | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
| FaxNumber: | 8188996501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 51738 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.