Provider Demographics
NPI:1922283845
Name:REZA, SANDRA ANN
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANN
Last Name:REZA
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 1:1135 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3523
Mailing Address - Country:US
Mailing Address - Phone:909-888-6956
Mailing Address - Fax:909-381-6845
Practice Address - Street 1:1135 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3523
Practice Address - Country:US
Practice Address - Phone:909-888-6956
Practice Address - Fax:909-381-6845
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360004FN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)