Provider Demographics
NPI:1760946131
Name:BURSIAGA, SASHA RENEE
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:RENEE
Last Name:BURSIAGA
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 1:4151 N BLYTHE AVE APT 258
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6380
Mailing Address - Country:US
Mailing Address - Phone:559-936-9488
Mailing Address - Fax:
Practice Address - Street 1:4151 N BLYTHE AVE APT 258
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-6380
Practice Address - Country:US
Practice Address - Phone:559-936-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-75350106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician