MEDICARE: CLARISSA A SANDOVAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1255744199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA A SANDOVAL

Provider Business Mailing Address
First Line	:	5203 JUAN TABO BLVD NE
Second Line	:	2 A
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2683
Country	:	US
Telephone Number	:	505-266-6121
Fax Number	:	505-221-5710

Provider Business Practice Location Address
First Line	:	5203 JUAN TABO BLVD NE
Second Line	:	2 A
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2683
Country	:	US
Telephone Number	:	505-273-2512
Fax Number	:	505-221-5710

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/09/2014

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Directions to “ CLARISSA A SANDOVAL ” Practice Location

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