Provider Demographics
NPI:1962912048
Name:SANDOVAL, INGRID (MA)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W VENTURA BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-9142
Mailing Address - Country:US
Mailing Address - Phone:858-264-5858
Mailing Address - Fax:858-649-6012
Practice Address - Street 1:400 W VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-9137
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
45-3589857OtherTHE HOLMAN GROUP