Provider Demographics
NPI:1548971716
Name:KUMASAKA MATSUDA, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:KUMASAKA MATSUDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14019 SAN SEGUNDO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2150
Mailing Address - Country:US
Mailing Address - Phone:801-946-2480
Mailing Address - Fax:
Practice Address - Street 1:23461 S POINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1523
Practice Address - Country:US
Practice Address - Phone:949-452-0888
Practice Address - Fax:949-452-0889
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC18012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YP2500XOtherOUTPATIENT MENTAL HEALTH