Provider Demographics
NPI:1164152773
Name:SANCHEZ, ELISSA MONIQUE
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:MONIQUE
Last Name:SANCHEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 N BATES AVE APT J
Mailing Address - Street 2:
Mailing Address - City:DINUBA
Mailing Address - State:CA
Mailing Address - Zip Code:93618-3079
Mailing Address - Country:US
Mailing Address - Phone:559-393-9714
Mailing Address - Fax:
Practice Address - Street 1:7226 SEPULVEDA BLVD. VAN NUYS,
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-235-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91348343D30127Medicaid