Provider Demographics
NPI:1295511871
Name:VIZCAINO-SANDOVAL, LIZETH (AGENCY AFFILIATED CO)
Entity type:Individual
Prefix:
First Name:LIZETH
Middle Name:
Last Name:VIZCAINO-SANDOVAL
Suffix:
Gender:F
Credentials:AGENCY AFFILIATED CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 22ND ST APT 207
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6872
Mailing Address - Country:US
Mailing Address - Phone:509-415-8810
Mailing Address - Fax:
Practice Address - Street 1:1601 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5612
Practice Address - Country:US
Practice Address - Phone:360-763-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61371732101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health