Provider Demographics
NPI:1528590262
Name:ELLERBE, SANDI ROSE (SUDCC 8646)
Entity Type:Individual
Prefix:MRS
First Name:SANDI
Middle Name:ROSE
Last Name:ELLERBE
Suffix:
Gender:F
Credentials:SUDCC 8646
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 COURAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6717
Mailing Address - Country:US
Mailing Address - Phone:707-639-4675
Mailing Address - Fax:707-639-4700
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-639-4675
Practice Address - Fax:707-639-4700
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8646101YA0400X
101YM0800X, 172V00000X, 175T00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer Specialist