Provider Demographics
NPI:1194004861
Name:SANDOVAL, CRISTINA LUCIA
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:LUCIA
Last Name:SANDOVAL
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 1:4618 FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1977
Mailing Address - Country:US
Mailing Address - Phone:323-669-4355
Mailing Address - Fax:323-953-7300
Practice Address - Street 1:4618 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1977
Practice Address - Country:US
Practice Address - Phone:323-669-4355
Practice Address - Fax:323-953-7300
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA680171041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical