Provider Demographics
NPI:1780819474
Name:RUSSELL, SANDRA (MFT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1982
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-1982
Mailing Address - Country:US
Mailing Address - Phone:916-213-1017
Mailing Address - Fax:530-622-2793
Practice Address - Street 1:7996 OLD WINDING WAY STE 210
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7159
Practice Address - Country:US
Practice Address - Phone:916-213-1017
Practice Address - Fax:530-622-2793
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2009-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT47160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist