Provider Demographics
NPI:1598475915
Name:SUONG, SANDRA MIA (MS MFT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MIA
Last Name:SUONG
Suffix:
Gender:F
Credentials:MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CONCORD ST APT B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2800
Mailing Address - Country:US
Mailing Address - Phone:818-370-5993
Mailing Address - Fax:
Practice Address - Street 1:1250 E WALNUT ST STE 110
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1877
Practice Address - Country:US
Practice Address - Phone:818-370-5993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48853106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA4012793OtherDRIVERS LICENSE