Provider Demographics
NPI:1386135168
Name:SANDOVAL, VENASSA (LMT)
Entity type:Individual
Prefix:
First Name:VENASSA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 HEARTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5835
Mailing Address - Country:US
Mailing Address - Phone:702-677-6164
Mailing Address - Fax:
Practice Address - Street 1:2204 HAGERMAN ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3741
Practice Address - Country:US
Practice Address - Phone:719-331-6901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0019938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT0019938OtherCOLORADO DEPT OF REGULATORY AGENCIES DIVISION OF PROFESSIONS AND OCCUPATIONS