Healthcare Provider Details

I. General information

NPI: 1710811492
Provider Name (Legal Business Name): MS. SANDRA HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA HEREDIA VAZQUEZ

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E BATTLES RD
SANTA MARIA CA
93454-7211
US

IV. Provider business mailing address

708 S MILLER ST
SANTA MARIA CA
93454-6230
US

V. Phone/Fax

Practice location:
  • Phone: 805-345-6242
  • Fax:
Mailing address:
  • Phone: 805-345-6242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number220147222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: