Provider Demographics
NPI:1467104612
Name:SANDOVAL, DEANNA (CRC, LPC)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PINE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2643
Mailing Address - Country:US
Mailing Address - Phone:872-242-0989
Mailing Address - Fax:
Practice Address - Street 1:75 PINE AVE APT 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2643
Practice Address - Country:US
Practice Address - Phone:872-242-0989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016401101YP2500X
IL397724225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty