Healthcare Provider Details

I. General information

NPI: 1477999647
Provider Name (Legal Business Name): AYSAN ANNELISE SANDOVAL MS NCC CPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3376 S EASTERN AVE STE 160
LAS VEGAS NV
89169-3388
US

IV. Provider business mailing address

4017 KEASBERRY AVE
NORTH LAS VEGAS NV
89081-6693
US

V. Phone/Fax

Practice location:
  • Phone: 702-490-9009
  • Fax: 866-737-6147
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCP3048
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: