Provider Demographics
NPI:1255744199
Name:SANDOVAL, CLARISSA A
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:A
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:A
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5203 JUAN TABO BLVD NE
Mailing Address - Street 2:2 A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2683
Mailing Address - Country:US
Mailing Address - Phone:505-266-6121
Mailing Address - Fax:505-221-5710
Practice Address - Street 1:5203 JUAN TABO BLVD NE
Practice Address - Street 2:2 A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2683
Practice Address - Country:US
Practice Address - Phone:505-273-2512
Practice Address - Fax:505-221-5710
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor