Provider Demographics
NPI:1326286840
Name:TISDALE, SARAH ANNE (MFT 79763)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ANNE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MFT 79763
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2634
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-2634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 ENCINAL ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2178
Practice Address - Country:US
Practice Address - Phone:318-269-3623
Practice Address - Fax:833-371-1900
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#