Provider Demographics
NPI:1578189643
Name:SANDOVAL, IRISARILU (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:IRISARILU
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N 5TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935-1582
Mailing Address - Country:US
Mailing Address - Phone:304-243-8310
Mailing Address - Fax:304-243-8430
Practice Address - Street 1:222 N 5TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-1582
Practice Address - Country:US
Practice Address - Phone:304-243-8310
Practice Address - Fax:304-243-8430
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP13858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist