Healthcare Provider Details

I. General information

NPI: 1740623040
Provider Name (Legal Business Name): MR. GABRIEL JAMES SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 RUBY AVE
EUGENE OR
97404
US

IV. Provider business mailing address

715 SW RAMSEY AVE
GRANTS PASS OR
97527-5500
US

V. Phone/Fax

Practice location:
  • Phone: 541-461-3075
  • Fax: 541-461-1361
Mailing address:
  • Phone: 541-956-4943
  • Fax: 541-956-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: