Provider Demographics
NPI:1578321170
Name:SANDOVAL, SAMANTHA R
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
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 1:11200 W CAMELBACK RD UNIT 153
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5089
Mailing Address - Country:US
Mailing Address - Phone:626-469-9137
Mailing Address - Fax:
Practice Address - Street 1:220 E. LA CANADA BLVD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-772-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP14699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist