Provider Demographics
NPI:1467434951
Name:SANDERSON, STACEY M (LMFT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:M
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N MOUNTAIN AVE STE C205G
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4315
Mailing Address - Country:US
Mailing Address - Phone:951-285-8662
Mailing Address - Fax:
Practice Address - Street 1:600 N MOUNTAIN AVE STE C205G
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4315
Practice Address - Country:US
Practice Address - Phone:195-128-5866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39382106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist