Provider Demographics
NPI:1093207631
Name:DE SILVA, SANDRA (MA, PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DE SILVA
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, PHD
Mailing Address - Street 1:1460 7TH ST STE 303
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 7TH ST STE 303
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2632
Practice Address - Country:US
Practice Address - Phone:310-916-6549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20930103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical