Provider Demographics
NPI:1235231440
Name:SANDOVAL, CIRILO (LCSW)
Entity Type:Individual
Prefix:
First Name:CIRILO
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2687
Mailing Address - Country:US
Mailing Address - Phone:505-443-2800
Mailing Address - Fax:
Practice Address - Street 1:1200 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2687
Practice Address - Country:US
Practice Address - Phone:505-443-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-11391041C0700X
NMI-11391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1235231440Medicaid
NMA0175Medicaid
NM345525601Medicare ID - Type Unspecified