Provider Demographics
NPI:1063142883
Name:SANDOVAL, AMANDA NICHOLLE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLLE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-4609
Mailing Address - Country:US
Mailing Address - Phone:361-228-5312
Mailing Address - Fax:
Practice Address - Street 1:9760 LA BRANCH DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-1538
Practice Address - Country:US
Practice Address - Phone:261-903-6528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116134OtherSPEECH LANGUAGE PATHOLOGIST TX