Provider Demographics
NPI:1215674577
Name:SANDS, MICHAEL LAURENCE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAURENCE
Last Name:SANDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2535
Mailing Address - Country:US
Mailing Address - Phone:909-398-4383
Mailing Address - Fax:
Practice Address - Street 1:831 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:909-398-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1473340622101YA0400X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty