Provider Demographics
NPI:1962695627
Name:SANDERSON, MARVIN (LMFT 99394)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:LMFT 99394
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 W EL SEGUNDO BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3315
Mailing Address - Country:US
Mailing Address - Phone:323-241-6740
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD FL 3
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4128
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99394106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist