Provider Demographics
NPI:1720245798
Name:SANDOVAL, GENARO JR (BA, LCDC)
Entity type:Individual
Prefix:MR
First Name:GENARO
Middle Name:
Last Name:SANDOVAL
Suffix:JR
Gender:M
Credentials:BA, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E STASSNEY LN APT 437
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-3253
Mailing Address - Country:US
Mailing Address - Phone:512-659-3518
Mailing Address - Fax:512-252-8764
Practice Address - Street 1:7703 N LAMAR BLVD STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-1003
Practice Address - Country:US
Practice Address - Phone:512-659-3518
Practice Address - Fax:512-252-8764
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10685101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)