Healthcare Provider Details

I. General information

NPI: 1235231440
Provider Name (Legal Business Name): CIRILO SANDOVAL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N PASEO DE ONATE
ESPANOLA NM
87532-2687
US

IV. Provider business mailing address

1200 N PASEO DE ONATE
ESPANOLA NM
87532-2687
US

V. Phone/Fax

Practice location:
  • Phone: 505-443-2800
  • Fax:
Mailing address:
  • Phone: 505-443-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-1139
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: