Healthcare Provider Details

I. General information

NPI: 1225346398
Provider Name (Legal Business Name): TINA LOUISE SANDOVAL-DYER MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 SONOMA AVE SUITE 117
SANTA ROSA CA
95405-4812
US

IV. Provider business mailing address

1144 SONOMA AVE SUITE 117
SANTA ROSA CA
95405-4812
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-7720
  • Fax: 707-526-1913
Mailing address:
  • Phone: 707-526-7720
  • Fax: 707-526-1913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number47943
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: