Provider Demographics
NPI:1093554925
Name:SANDOVAL, SANDY (CPSW)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 UNSER BLVD SE STE C
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6300
Mailing Address - Country:US
Mailing Address - Phone:505-636-6100
Mailing Address - Fax:
Practice Address - Street 1:12 UNSER BLVD SE STE C
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6300
Practice Address - Country:US
Practice Address - Phone:505-636-6100
Practice Address - Fax:505-501-8646
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00000171M00000X
NM1635175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator