Provider Demographics
NPI:1780153692
Name:MAYO, SANIYYAH SHALEECE
Entity type:Individual
Prefix:
First Name:SANIYYAH
Middle Name:SHALEECE
Last Name:MAYO
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 1:12223 HIGHLAND AVE # 106-580
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2574
Mailing Address - Country:US
Mailing Address - Phone:909-660-3624
Mailing Address - Fax:
Practice Address - Street 1:219 N EUCLID AVE STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-6038
Practice Address - Country:US
Practice Address - Phone:909-660-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty