Provider Demographics
NPI:1376015354
Name:SANDRALI, SERGE N
Entity Type:Individual
Prefix:
First Name:SERGE
Middle Name:N
Last Name:SANDRALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 W OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-2224
Mailing Address - Country:US
Mailing Address - Phone:480-938-6189
Mailing Address - Fax:
Practice Address - Street 1:4110 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-2224
Practice Address - Country:US
Practice Address - Phone:480-938-6189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician