Provider Demographics
NPI:1518456359
Name:SANDOVAL, LAURALISE
Entity Type:Individual
Prefix:
First Name:LAURALISE
Middle Name:
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 1:22539 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6822
Mailing Address - Country:US
Mailing Address - Phone:951-232-1736
Mailing Address - Fax:
Practice Address - Street 1:1616 E 4TH ST STE 220
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5145
Practice Address - Country:US
Practice Address - Phone:657-236-1287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician