Provider Demographics
NPI:1861041204
Name:SANDFORD, MELISSA ANN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:SANDFORD
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 1:6401 ACADEMY RD NE APT 95
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3316
Mailing Address - Country:US
Mailing Address - Phone:505-234-9816
Mailing Address - Fax:
Practice Address - Street 1:5203 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2683
Practice Address - Country:US
Practice Address - Phone:505-266-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-67160101YM0800X
NMCMH0207751101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health