Provider Demographics
NPI:1285796102
Name:SANGO, MATTIE LEE (ASW)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:LEE
Last Name:SANGO
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BECK AVE
Mailing Address - Street 2:MD5-200
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6804
Mailing Address - Country:US
Mailing Address - Phone:707-399-4988
Mailing Address - Fax:707-399-4999
Practice Address - Street 1:1745 ENTERPRISE DR # MS 2-230
Practice Address - Street 2:BLDG. 2, STE. 2A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5801
Practice Address - Country:US
Practice Address - Phone:707-399-4988
Practice Address - Fax:707-399-4999
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical