Provider Demographics
NPI:1255832697
Name:SANDLIN, MARK DENNIS (MA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DENNIS
Last Name:SANDLIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 S HEPNER AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-2508
Mailing Address - Country:US
Mailing Address - Phone:626-825-2063
Mailing Address - Fax:
Practice Address - Street 1:1111 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3205
Practice Address - Country:US
Practice Address - Phone:626-771-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91727106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist