Provider Demographics
NPI:1023441300
Name:SANDOVAL, SUZETTE L (EDS)
Entity type:Individual
Prefix:
First Name:SUZETTE
Middle Name:L
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 GRIEGOS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3336
Mailing Address - Country:US
Mailing Address - Phone:505-228-4619
Mailing Address - Fax:
Practice Address - Street 1:5323 MENAUL ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87176
Practice Address - Country:US
Practice Address - Phone:505-889-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM279940103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool