Provider Demographics
NPI:1811011364
Name:FARLEY, SALLY MARIE
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:MARIE
Last Name:FARLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:MARIE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:1827 ATLANTA AVE
Mailing Address - Street 2:SUITE D2
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7419
Mailing Address - Country:US
Mailing Address - Phone:951-955-8210
Mailing Address - Fax:
Practice Address - Street 1:1827 ATLANTA AVE
Practice Address - Street 2:SUITE D2
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7419
Practice Address - Country:US
Practice Address - Phone:951-955-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist