Healthcare Provider Details

I. General information

NPI: 1659926491
Provider Name (Legal Business Name): NICOLE SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17120 OMEGA STREET
ESPARTO CA
95627
US

IV. Provider business mailing address

17340 YOLO AVE
ESPARTO CA
95627-2265
US

V. Phone/Fax

Practice location:
  • Phone: 530-787-3417
  • Fax:
Mailing address:
  • Phone: 530-787-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number160340
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number21147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: