MEDICARE: MARIA ELENA 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	101YM0800X	Mental Health Counselor	364465-3501	UT

General Provider Information

NPI Number	:	1659012128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA ELENA SANDOVAL

Provider Business Mailing Address
First Line	:	477 N JEFFERSON AVE
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3739
Country	:	US
Telephone Number	:	801-644-1646
Fax Number	:

Provider Business Practice Location Address
First Line	:	477 N JEFFERSON AVE
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3739
Country	:	US
Telephone Number	:	801-644-1646
Fax Number	:

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

Provider Enumeration Date	:	04/06/2022
Last Update Date	:	04/06/2022

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Directions to “ MARIA ELENA SANDOVAL ” Practice Location

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