Provider Demographics
NPI:1073224879
Name:SANDOVAL GONZALEZ, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SANDOVAL GONZALEZ
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 1:17824 DORSEY ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-4021
Mailing Address - Country:US
Mailing Address - Phone:909-515-2945
Mailing Address - Fax:
Practice Address - Street 1:17824 DORSEY ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-4021
Practice Address - Country:US
Practice Address - Phone:909-515-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty