Provider Demographics
NPI:1013423318
Name:DACOSTA, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:DACOSTA
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 1:1455 S STATE ST SPC 206
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-7604
Mailing Address - Country:US
Mailing Address - Phone:951-667-0106
Mailing Address - Fax:
Practice Address - Street 1:8300 UTICA AVE STE 259
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3852
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:909-906-1508
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician