Provider Demographics
NPI:1821447541
Name:SANDOVAL, STEPHANIE MICHELLE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 BISSO LN STE 200
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4886
Mailing Address - Country:US
Mailing Address - Phone:925-646-5468
Mailing Address - Fax:
Practice Address - Street 1:2425 BISSO LN STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4886
Practice Address - Country:US
Practice Address - Phone:925-646-5468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA1070681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program