Provider Demographics
NPI:1225734486
Name:HOUSTON, SANDRA ALTHEA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ALTHEA
Last Name:HOUSTON
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 1:1423 CHICHESTER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1117
Mailing Address - Country:US
Mailing Address - Phone:407-353-9394
Mailing Address - Fax:
Practice Address - Street 1:1775 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5067
Practice Address - Country:US
Practice Address - Phone:407-606-7858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1225734486Medicaid
FLH235781669190OtherDRIVERS LICENSE
FL572149297OtherPASSPORT