Provider Demographics
NPI:1003392465
Name:MONTELONGO SEVILLA, SANDRA NAYELI
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:NAYELI
Last Name:MONTELONGO SEVILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S BEAUDRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1466
Mailing Address - Country:US
Mailing Address - Phone:818-993-9311
Mailing Address - Fax:
Practice Address - Street 1:333 S BEAUDRY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1466
Practice Address - Country:US
Practice Address - Phone:818-993-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW953621041C0700X
CA953621041C0700X
390200000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program