Provider Demographics
NPI:1568898443
Name:SANDOVAL, LORY CRYSTAL (DPC, LPC)
Entity Type:Individual
Prefix:DR
First Name:LORY
Middle Name:CRYSTAL
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:DPC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7002 AVENIDA DEL PASEO ST
Mailing Address - Street 2:
Mailing Address - City:PALMVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78572-1849
Mailing Address - Country:US
Mailing Address - Phone:956-222-9942
Mailing Address - Fax:
Practice Address - Street 1:1512 E GRIFFIN PKWY
Practice Address - Street 2:SUITE 8
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2416
Practice Address - Country:US
Practice Address - Phone:956-424-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3321309-01Medicaid
TX68787OtherLPC LICENSING BOARD OF TEXAS