Provider Demographics
NPI:1730690728
Name:KNICKERBOCKER, SANDRA LEE (LMFT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 MISSION GORGE RD SPC 86
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3580
Mailing Address - Country:US
Mailing Address - Phone:619-937-1900
Mailing Address - Fax:
Practice Address - Street 1:2816 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1401
Practice Address - Country:US
Practice Address - Phone:619-937-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108057106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3704Medicaid