Provider Demographics
NPI:1073742268
Name:BAHENA-COLLEY, SANDRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:BAHENA-COLLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:BAHENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-564-8765
Mailing Address - Fax:
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-564-8765
Practice Address - Fax:619-564-8786
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY29792103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist