Provider Demographics
NPI:1063028322
Name:SANDOVAL, ENLI ANGELICA
Entity type:Individual
Prefix:
First Name:ENLI
Middle Name:ANGELICA
Last Name:SANDOVAL
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 1:872 PORTSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-6461
Mailing Address - Country:US
Mailing Address - Phone:209-756-4655
Mailing Address - Fax:
Practice Address - Street 1:720 SUNRISE AVE STE 200C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4508
Practice Address - Country:US
Practice Address - Phone:916-360-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT146404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist