Basic Information
| Provider Information | |||||||||
| NPI: | 1972855823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERNABE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LETICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 W SUNSET BLVD. MS# 53 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233613849 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4650 SUNSET BLVD. MS #53 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233613849 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2012 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ASW72584 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LCSW92729 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.