Healthcare Provider Details

I. General information

NPI: 1669918777
Provider Name (Legal Business Name): SARA CUMMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 04/01/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27472 PORTOLA PKWY # 205-127
FOOTHILL RANCH CA
92610-2853
US

IV. Provider business mailing address

27472 PORTOLA PKWY # 205-127
FOOTHILL RANCH CA
92610-2853
US

V. Phone/Fax

Practice location:
  • Phone: 714-404-8877
  • Fax:
Mailing address:
  • Phone: 714-404-8877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF88511
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: