MEDICARE: MR. GENARO SANDOVAL JR. B.A., LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	10685	TX

General Provider Information

NPI Number	:	1720245798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GENARO SANDOVAL JR. B.A., LCDC

Provider Business Mailing Address
First Line	:	500 E STASSNEY LN APT 437
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-3253
Country	:	US
Telephone Number	:	512-659-3518
Fax Number	:	512-252-8764

Provider Business Practice Location Address
First Line	:	7703 N LAMAR BLVD STE 104
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78752-1003
Country	:	US
Telephone Number	:	512-659-3518
Fax Number	:	512-252-8764

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/05/2009

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