Provider Demographics
NPI:1154656908
Name:PEREZ, SANDRA LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1510 FLORIDA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4437
Practice Address - Country:US
Practice Address - Phone:209-574-1030
Practice Address - Fax:209-574-1038
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS155201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS15520OtherMEDICAL LICENSE