Healthcare Provider Details

I. General information

NPI: 1831558832
Provider Name (Legal Business Name): SANDRA DURON THOMAS D1007310950
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W. EL SEGUNDO BLVD
HAWTHORNE CA
90250
US

IV. Provider business mailing address

9534 CEDAR ST
BELLFLOWER CA
90706-6577
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-2816
  • Fax:
Mailing address:
  • Phone: 562-461-9272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberD1007310950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: