Healthcare Provider Details

I. General information

NPI: 1073130886
Provider Name (Legal Business Name): REBECCA ANNE-AU SANFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ANNE-AU SMITH

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MISSION ST STE 201
SAN MARINO CA
91108-1676
US

IV. Provider business mailing address

2600 MISSION ST STE 201
SAN MARINO CA
91108-1676
US

V. Phone/Fax

Practice location:
  • Phone: 626-623-7478
  • Fax: 626-737-6034
Mailing address:
  • Phone: 626-623-7478
  • Fax: 626-737-6034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number91981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: