Provider Demographics
NPI:1265662324
Name:EARL, SANDRA J (MA LPCC)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:J
Last Name:EARL
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:EARL INC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:1813 HOPI RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3308
Mailing Address - Country:US
Mailing Address - Phone:505-660-3607
Mailing Address - Fax:
Practice Address - Street 1:1813 HOPI RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3308
Practice Address - Country:US
Practice Address - Phone:505-660-3607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02960670005OtherCRS
NM80-0435792OtherEIN
NM27-3930503OtherSANDRA EARL INC (EIN NUMBER)