Provider Demographics
NPI:1134828403
Name:SARA PROVENCE LMFT
Entity type:Organization
Organization Name:SARA PROVENCE LMFT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMFT (THERAPIST)
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-354-2249
Mailing Address - Street 1:9528 MIRAMAR RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3455 INGRAHAM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-6713
Practice Address - Country:US
Practice Address - Phone:619-723-6004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty