Healthcare Provider Details

I. General information

NPI: 1437894847
Provider Name (Legal Business Name): DORA J SANDOVAL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DORA J SANDOVAL LMSW

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 STAGECOACH RD SE
ALBUQUERQUE NM
87123-4126
US

IV. Provider business mailing address

725 STAGECOACH RD SE
ALBUQUERQUE NM
87123-4126
US

V. Phone/Fax

Practice location:
  • Phone: 505-489-2094
  • Fax:
Mailing address:
  • Phone: 505-489-2094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM-10257
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: