Healthcare Provider Details

I. General information

NPI: 1023441300
Provider Name (Legal Business Name): SUZETTE L SANDOVAL EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 MENAUL ST NE
ALBUQUERQUE NM
87176
US

IV. Provider business mailing address

1735 GRIEGOS RD NW
ALBUQUERQUE NM
87107-3336
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-3412
  • Fax:
Mailing address:
  • Phone: 505-228-4619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number279940
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: