Provider Demographics
NPI:1255087805
Name:DUFFIELD, SANDRA GAYLE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:GAYLE
Last Name:DUFFIELD
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 1:1471 KEYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-7439
Mailing Address - Country:US
Mailing Address - Phone:909-210-1505
Mailing Address - Fax:
Practice Address - Street 1:9033 BASE LINE RD STE K
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1214
Practice Address - Country:US
Practice Address - Phone:909-210-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC6374443OtherNO INSURANCE AT THIS TIME