Provider Demographics
NPI:1295041614
Name:SANDOVAL, REYNIE THOMAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:REYNIE
Middle Name:THOMAS
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 1:853 N 1200 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3526
Mailing Address - Country:US
Mailing Address - Phone:801-473-8844
Mailing Address - Fax:
Practice Address - Street 1:853 N 1200 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3526
Practice Address - Country:US
Practice Address - Phone:801-473-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4976881-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical