Provider Demographics
NPI:1275906695
Name:SANBORN, ERICA M
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:M
Last Name:SANBORN
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 1:11500 W OLYMPIC BLVD STE 615
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1530
Mailing Address - Country:US
Mailing Address - Phone:424-209-2592
Mailing Address - Fax:
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:424-209-2592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL