Provider Demographics
NPI:1659012128
Name:SANDOVAL, MARIA ELENA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELENA
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 1:477 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3739
Mailing Address - Country:US
Mailing Address - Phone:801-644-1646
Mailing Address - Fax:
Practice Address - Street 1:477 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-3739
Practice Address - Country:US
Practice Address - Phone:801-644-1646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT364465-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health