Provider Demographics
NPI:1306159835
Name:SANDOVAL, AMANDA (SLPA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9722 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2602
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:98 BRIGGS ST
Practice Address - Street 2:SUITE 990
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1286
Practice Address - Country:US
Practice Address - Phone:210-226-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX676535Medicare UPIN
TX456606Medicare UPIN