Provider Demographics
NPI:1114282035
Name:SANDOVAL, PHILLIP A (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5152 OAK SHADE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4167
Mailing Address - Country:US
Mailing Address - Phone:916-642-6419
Mailing Address - Fax:
Practice Address - Street 1:5152 OAK SHADE WAY
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4167
Practice Address - Country:US
Practice Address - Phone:916-642-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF63514106H00000X
CA80303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist