Provider Demographics
NPI:1093024473
Name:MANSOUR, SANDRA (MA)
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 W SHAW AVE
Mailing Address - Street 2:SULLIVAN CENTER FOR CHILDREN
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3249
Mailing Address - Country:US
Mailing Address - Phone:559-271-1176
Mailing Address - Fax:
Practice Address - Street 1:3443 W SHAW AVE
Practice Address - Street 2:SULLIVAN CENTER FOR CHILDREN
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3249
Practice Address - Country:US
Practice Address - Phone:559-271-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB 35440103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent