Provider Demographics
NPI:1801902549
Name:SUDLER, DEANA KAY (MFT)
Entity type:Individual
Prefix:MS
First Name:DEANA
Middle Name:KAY
Last Name:SUDLER
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 1:528 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6729
Mailing Address - Country:US
Mailing Address - Phone:909-793-7890
Mailing Address - Fax:
Practice Address - Street 1:23119 COTTONWOOD AVE BLDG B
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9662
Practice Address - Country:US
Practice Address - Phone:951-413-5579
Practice Address - Fax:951-413-5801
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT15126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT15126OtherMFT LICENSE #