Healthcare Provider Details

I. General information

NPI: 1558281436
Provider Name (Legal Business Name): SARA ELIZABETH SLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7460 MISSION VALLEY RD STE 200
SAN DIEGO CA
92108-4438
US

IV. Provider business mailing address

3916 RIVIERA DR UNIT 205
SAN DIEGO CA
92109-5831
US

V. Phone/Fax

Practice location:
  • Phone: 619-376-6653
  • Fax: 619-768-0339
Mailing address:
  • Phone: 602-469-1443
  • Fax: 619-768-0339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: