Provider Demographics
NPI:1255375036
Name:FACTOR, SANDRA - (MFT,)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:-
Last Name:FACTOR
Suffix:
Gender:F
Credentials:MFT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-0844
Mailing Address - Country:US
Mailing Address - Phone:707-616-7428
Mailing Address - Fax:707-677-3241
Practice Address - Street 1:1611 PENINSULA DR
Practice Address - Street 2:SUITE E
Practice Address - City:MANILA
Practice Address - State:CA
Practice Address - Zip Code:95521-9658
Practice Address - Country:US
Practice Address - Phone:707-616-7428
Practice Address - Fax:707-677-3241
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 29508106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 29508OtherMARRIAGE FAMILY THERAPIST