Provider Demographics
NPI:1710253760
Name:SLATER, SANFORD JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:JAY
Last Name:SLATER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 FLINTRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-3806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MARINA DR
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6023
Practice Address - Country:US
Practice Address - Phone:562-431-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12757103TC0700X
NY018742-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical