=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104338128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YVONNE SANDOVAL AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2921 CARLISLE BLVD NE STE 111
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-421-0242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 114
-----------------------------------------------------
City | VILLANUEVA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87583-0114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-421-0242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. YVONNE TERESA SANDOVAL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 720-297-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | C-10093
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------