Healthcare Provider Details

I. General information

NPI: 1598475915
Provider Name (Legal Business Name): SANDRA MIA SUONG MS MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E WALNUT ST STE 110
PASADENA CA
91106-1877
US

IV. Provider business mailing address

330 CONCORD ST APT B
GLENDALE CA
91203-2800
US

V. Phone/Fax

Practice location:
  • Phone: 818-370-5993
  • Fax:
Mailing address:
  • Phone: 818-370-5993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number48853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: