MEDICARE: SANDRA MIA SUONG MS MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	48853	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A4012793	OTHER	CA	DRIVERS LICENSE

General Provider Information

NPI Number	:	1598475915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA MIA SUONG MS MFT

Provider Business Mailing Address
First Line	:	330 CONCORD ST APT B
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-2800
Country	:	US
Telephone Number	:	818-370-5993
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E WALNUT ST STE 110
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1877
Country	:	US
Telephone Number	:	818-370-5993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2022
Last Update Date	:	11/28/2022

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