Healthcare Provider Details

I. General information

NPI: 1003063512
Provider Name (Legal Business Name): SANDRA MAURA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WAVECREST AVE
SANTA CRUZ CA
95060-3020
US

IV. Provider business mailing address

103 WAVECREST AVE
SANTA CRUZ CA
95060-3020
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-5971
  • Fax: 831-425-5971
Mailing address:
  • Phone: 831-425-5971
  • Fax: 831-425-5971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 21503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: