Provider Demographics
NPI:1275108904
Name:SANDOVAL, ADAM ABRAHAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:ABRAHAM
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9462 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1310
Mailing Address - Country:US
Mailing Address - Phone:818-891-8555
Mailing Address - Fax:
Practice Address - Street 1:9462 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-1310
Practice Address - Country:US
Practice Address - Phone:818-891-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)