Provider Demographics
NPI:1811629421
Name:FETHEROLF, SANDRA KAY (LMFT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:FETHEROLF
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13107 HAGAR ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4843
Mailing Address - Country:US
Mailing Address - Phone:626-319-8955
Mailing Address - Fax:
Practice Address - Street 1:13107 HAGAR ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4843
Practice Address - Country:US
Practice Address - Phone:626-319-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329024106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist