Healthcare Provider Details

I. General information

NPI: 1083521546
Provider Name (Legal Business Name): LISET SANDOVAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E WALNUT ST
PASADENA CA
91188-0001
US

IV. Provider business mailing address

393 E WALNUT ST
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 833-511-0106
  • Fax:
Mailing address:
  • Phone: 833-511-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: