Basic Information
| Provider Information | |||||||||
| NPI: | 1669483954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANNENBAUM | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 S MCCLINTOCK DR | ||||||||
| Address2: | SUITE 103-174 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852841695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804524797 | ||||||||
| FaxNumber: | 4802642763 | ||||||||
| Practice Location | |||||||||
| Address1: | 7650 S MCCLINTOCK DR | ||||||||
| Address2: | SUITE 103-174 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852841695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804524797 | ||||||||
| FaxNumber: | 4807187859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 3828 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 128424 | 05 | AZ | MEDICAID |