Provider Demographics
NPI:1073130886
Name:SANFORD, REBECCA ANNE-AU
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE-AU
Last Name:SANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANNE-AU
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 MISSION ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1676
Mailing Address - Country:US
Mailing Address - Phone:626-623-7478
Mailing Address - Fax:626-737-6034
Practice Address - Street 1:2600 MISSION ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-1676
Practice Address - Country:US
Practice Address - Phone:626-623-7478
Practice Address - Fax:626-737-6034
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA919811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91981OtherBBS