Provider Demographics
NPI:1629341904
Name:SANDOVAL, MARIELA (MS)
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COLLEGE PARK GLASGOW AVE.
Mailing Address - Street 2:1899
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921
Mailing Address - Country:US
Mailing Address - Phone:787-238-8580
Mailing Address - Fax:
Practice Address - Street 1:GLASGOW AVE. COLLEGE PARK
Practice Address - Street 2:#1899
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-4834
Practice Address - Country:US
Practice Address - Phone:787-238-8580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1124225X00000X
PR5590103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist