Provider Demographics
NPI:1689158768
Name:WALZBERG, SANDRA SUE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
Last Name:WALZBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4534
Mailing Address - Country:US
Mailing Address - Phone:805-788-2063
Mailing Address - Fax:805-781-1372
Practice Address - Street 1:2191 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4534
Practice Address - Country:US
Practice Address - Phone:805-788-2063
Practice Address - Fax:805-781-1372
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283746251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management