Provider Demographics
NPI:1235517855
Name:SANDOVAL, RENE (BCBA)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E MUIRWOOD DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7639
Mailing Address - Country:US
Mailing Address - Phone:480-610-6981
Mailing Address - Fax:480-898-7419
Practice Address - Street 1:4530 E MUIRWOOD DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7639
Practice Address - Country:US
Practice Address - Phone:480-610-6981
Practice Address - Fax:480-898-7419
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-17744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst