Provider Demographics
NPI:1447960448
Name:SANFORD, BRENTON
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:
Last Name:SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 COLVIN ST STE 1-A
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5031
Mailing Address - Country:US
Mailing Address - Phone:703-936-6214
Mailing Address - Fax:
Practice Address - Street 1:3014 COLVIN ST STE 1-A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5031
Practice Address - Country:US
Practice Address - Phone:703-936-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VA0704017739101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health