Provider Demographics
NPI:1689270241
Name:SALLY, COLLEEN
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:SALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 MISSION ST UNIT 300
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5262
Mailing Address - Country:US
Mailing Address - Phone:831-427-1007
Mailing Address - Fax:
Practice Address - Street 1:380 ENCINAL ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2178
Practice Address - Country:US
Practice Address - Phone:831-400-6061
Practice Address - Fax:831-400-6061
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC20786101YP2500X
101YA0400X
CAAMFT158563106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)