Provider Demographics
NPI:1790233625
Name:ATHANASIOS, SANDRA (PSYD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:ATHANASIOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HUNTINGTON AVE
Mailing Address - Street 2:PO BOX: 1312
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-8000
Mailing Address - Country:US
Mailing Address - Phone:415-939-2624
Mailing Address - Fax:
Practice Address - Street 1:1408 CHAPIN AVE STE 3
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4080
Practice Address - Country:US
Practice Address - Phone:510-210-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical