Provider Demographics
NPI:1568640548
Name:SANDOVAL, JOSE A (PHD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 SW 40TH ST
Mailing Address - Street 2:SUITE# 321
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3372
Mailing Address - Country:US
Mailing Address - Phone:305-720-0237
Mailing Address - Fax:
Practice Address - Street 1:11401 SW 40TH ST
Practice Address - Street 2:SUITE 321
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3372
Practice Address - Country:US
Practice Address - Phone:305-720-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7539103T00000X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical