Provider Demographics
NPI:1598230054
Name:SANDOVAL, LUCILLE DEESI (LMSW)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:DEESI
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6240 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3733
Mailing Address - Country:US
Mailing Address - Phone:718-651-1980
Mailing Address - Fax:
Practice Address - Street 1:6240 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3733
Practice Address - Country:US
Practice Address - Phone:718-651-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102188104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker