Provider Demographics
NPI:1215221320
Name:SANDOVAL, CHARMAYNE N (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARMAYNE
Middle Name:N
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CHARMAYNE
Other - Middle Name:N
Other - Last Name:HYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2006
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-543-0171
Practice Address - Street 1:110 E ROUTT AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2117
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-0171
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COCSW.09923811103TC0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61502723Medicaid
CO61502723Medicaid