Provider Demographics
NPI:1639468895
Name:SANDOVAL, JUSTIN BASILIO ROSALES
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BASILIO ROSALES
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1129
Mailing Address - Country:US
Mailing Address - Phone:541-513-3162
Mailing Address - Fax:
Practice Address - Street 1:744 OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1129
Practice Address - Country:US
Practice Address - Phone:541-513-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health