Provider Demographics
NPI:1407384308
Name:WISZNIA, SACHA B
Entity type:Individual
Prefix:
First Name:SACHA
Middle Name:B
Last Name:WISZNIA
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 1:900 E GILBERT ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0936
Mailing Address - Country:US
Mailing Address - Phone:909-387-7406
Mailing Address - Fax:
Practice Address - Street 1:900EAST GILBERT STREET COTTAGE 4
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-4564
Practice Address - Country:US
Practice Address - Phone:909-387-7024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA732291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty