Provider Demographics
NPI:1932401932
Name:SANFORD, KATIE JO (MA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:SANFORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JO
Other - Last Name:KLOET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:12840 MOORPARK ST APT 209
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1392
Mailing Address - Country:US
Mailing Address - Phone:818-272-7111
Mailing Address - Fax:
Practice Address - Street 1:11650 RIVERSIDE DR STE 10
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91602
Practice Address - Country:US
Practice Address - Phone:818-272-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC3627101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional