Provider Demographics
NPI:1154186278
Name:SANDOVAL, ELIZABETH GRACE (LCMHCA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:GRACE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-9034
Mailing Address - Fax:
Practice Address - Street 1:131 W LEBANON ST STE C&E
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2935
Practice Address - Country:US
Practice Address - Phone:336-716-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19748101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health