Provider Demographics
NPI:1013596675
Name:SANDBERG, NINA LAURA (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:LAURA
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235554
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-5554
Mailing Address - Country:US
Mailing Address - Phone:858-367-9027
Mailing Address - Fax:619-600-0683
Practice Address - Street 1:130 W E ST
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3519
Practice Address - Country:US
Practice Address - Phone:858-367-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130411106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206KQP3HMedicaid