Provider Demographics
NPI:1477207843
Name:SANDOVAL, SUSAN LEIGH (CAT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80807-2613
Mailing Address - Country:US
Mailing Address - Phone:719-342-0586
Mailing Address - Fax:
Practice Address - Street 1:451 14TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1609
Practice Address - Country:US
Practice Address - Phone:719-297-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0021272101YA0400X
KSLAC01832101YA0400X
COACA.0008128101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COACC.0021272OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES
KSLAC01832OtherKANSAS BEHAVIORAL SCIENCES REGULATORY BOARD