Provider Demographics
NPI:1588128672
Name:SARMENTO, ELISA (MA, LADC)
Entity type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:
Last Name:SARMENTO
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4462 REINDEER LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2096
Mailing Address - Country:US
Mailing Address - Phone:949-566-5908
Mailing Address - Fax:
Practice Address - Street 1:4462 REINDEER LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2096
Practice Address - Country:US
Practice Address - Phone:949-566-5908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305289101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)