Provider Demographics
NPI:1508508532
Name:SANDOVAL, JOELIZ IDED
Entity Type:Individual
Prefix:
First Name:JOELIZ
Middle Name:IDED
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7137 ALTIS WAY APT 1-211
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-6872
Mailing Address - Country:US
Mailing Address - Phone:267-348-9188
Mailing Address - Fax:
Practice Address - Street 1:730 SAND LAKE RD STE 176
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7747
Practice Address - Country:US
Practice Address - Phone:407-412-6114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-18-5340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112006200Medicaid