Provider Demographics
NPI:1477999647
Name:SANDOVAL, AYSAN ANNELISE (MS NCC CPC)
Entity Type:Individual
Prefix:
First Name:AYSAN
Middle Name:ANNELISE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MS NCC CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 KEASBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3376 S EASTERN AVE STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3388
Practice Address - Country:US
Practice Address - Phone:702-490-9009
Practice Address - Fax:866-737-6147
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
NVCP3048101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health