Provider Demographics
NPI:1114054251
Name:CLEGG, SANDRA LEE (LMT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEE
Last Name:CLEGG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59-821 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-9407
Mailing Address - Country:US
Mailing Address - Phone:808-542-1192
Mailing Address - Fax:808-735-3503
Practice Address - Street 1:4747 KILAUEA AVE
Practice Address - Street 2:STE. 115
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5308
Practice Address - Country:US
Practice Address - Phone:808-542-1192
Practice Address - Fax:808-735-3503
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist