Healthcare Provider Details

I. General information

NPI: 1134828403
Provider Name (Legal Business Name): SARA PROVENCE LMFT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 INGRAHAM ST
SAN DIEGO CA
92109-6713
US

IV. Provider business mailing address

9528 MIRAMAR RD
SAN DIEGO CA
92126-4533
US

V. Phone/Fax

Practice location:
  • Phone: 619-723-6004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: SARA PROVENCE
Title or Position: LMFT (THERAPIST)
Credential: LMFT
Phone: 619-354-2249