Healthcare Provider Details

I. General information

NPI: 1043971377
Provider Name (Legal Business Name): SANDRA L BOHLE MA, MFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2022
Last Update Date: 09/11/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 S MARENGO AVE
PASADENA CA
91101-3128
US

IV. Provider business mailing address

491 S MARENGO AVE
PASADENA CA
91101-3128
US

V. Phone/Fax

Practice location:
  • Phone: 424-341-1977
  • Fax:
Mailing address:
  • Phone: 424-341-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number112620
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: