Healthcare Provider Details

I. General information

NPI: 1164512604
Provider Name (Legal Business Name): SANDRA LYNN CANTRELL LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 11TH ST STE 11B
MODESTO CA
95354-2339
US

IV. Provider business mailing address

PO BOX 323
HILMAR CA
95324-0323
US

V. Phone/Fax

Practice location:
  • Phone: 209-614-8226
  • Fax: 209-576-1470
Mailing address:
  • Phone: 209-667-0396
  • Fax: 209-576-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: