Provider Demographics
NPI:1902496110
Name:SANDAN, JICELLE-RAE FAUSTO (BCBA)
Entity type:Individual
Prefix:
First Name:JICELLE-RAE
Middle Name:FAUSTO
Last Name:SANDAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 E CAMELBACK RD APT 348
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4476
Mailing Address - Country:US
Mailing Address - Phone:757-802-0685
Mailing Address - Fax:
Practice Address - Street 1:2730 S VAL VISTA DR BLDG 4
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1675
Practice Address - Country:US
Practice Address - Phone:480-608-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2025-01-06
Deactivation Date:2024-08-09
Deactivation Code:
Reactivation Date:2024-10-07
Provider Licenses
StateLicense IDTaxonomies
1-24-73238103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst