Provider Demographics
NPI:1366706806
Name:DERTSAKYAN, SRBUI SABRINA (MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:SRBUI
Middle Name:SABRINA
Last Name:DERTSAKYAN
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1282
Mailing Address - Country:US
Mailing Address - Phone:209-333-1222
Mailing Address - Fax:
Practice Address - Street 1:1745 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5801
Practice Address - Country:US
Practice Address - Phone:510-318-4461
Practice Address - Fax:707-419-4952
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging