Provider Demographics
NPI:1659847424
Name:WISDOM, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:WISDOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-II
Mailing Address - Street 1:25837 OAK ST UNIT 108
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-3173
Mailing Address - Country:US
Mailing Address - Phone:310-378-9680
Mailing Address - Fax:
Practice Address - Street 1:1334 POST AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2620
Practice Address - Country:US
Practice Address - Phone:310-328-1460
Practice Address - Fax:310-328-1964
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA046801117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA046801117OtherCCAPP CREDENTIALING