Healthcare Provider Details

I. General information

NPI: 1093404626
Provider Name (Legal Business Name): NICHOLAUS SANDOVAL ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 TEXAS AVE
LOS BANOS CA
93635-3453
US

IV. Provider business mailing address

2900 CURTION AVE
TURLOCK CA
95380-6408
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax: 209-826-0952
Mailing address:
  • Phone: 209-225-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW133593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: