Basic Information
| Provider Information | |||||||||
| NPI: | 1780819474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1982 | ||||||||
| Address2: | |||||||||
| City: | FAIR OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956281982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162131017 | ||||||||
| FaxNumber: | 5306222793 | ||||||||
| Practice Location | |||||||||
| Address1: | 7996 OLD WINDING WAY STE 210 | ||||||||
| Address2: | |||||||||
| City: | FAIR OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956287159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162131017 | ||||||||
| FaxNumber: | 5306222793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2009 | ||||||||
| LastUpdateDate: | 05/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT47160 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.