=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891460309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRALEE DEVILLE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4280 LATHAM ST STE G
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-295-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27431 SAN BERNARDINO AVE APT 227
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-5085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-732-2731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 124647
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------