Healthcare Provider Details

I. General information

NPI: 1922283845
Provider Name (Legal Business Name): SANDRA ANN REZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 N D ST
SAN BERNARDINO CA
92410-3523
US

IV. Provider business mailing address

1135 N D ST
SAN BERNARDINO CA
92410-3523
US

V. Phone/Fax

Practice location:
  • Phone: 909-888-6956
  • Fax: 909-381-6845
Mailing address:
  • Phone: 909-888-6956
  • Fax: 909-381-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number360004FN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: