Provider Demographics
NPI:1306096987
Name:SANDOVAL, KELLY MARIE (DPT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:GAGALANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:433 SOSCOL
Mailing Address - Street 2:#B191
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558
Mailing Address - Country:US
Mailing Address - Phone:707-224-3131
Mailing Address - Fax:707-224-2356
Practice Address - Street 1:433 SOSCOL
Practice Address - Street 2:#B191
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4040
Practice Address - Country:US
Practice Address - Phone:707-224-3131
Practice Address - Fax:707-224-2356
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist