Provider Demographics
NPI:1760527105
Name:SANDOVAL, MELISSA ROSE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ROSE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ROSE
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:103 LANDMARK DRIVE STE 300
Mailing Address - Street 2:DEPARTMENT OF VETERAN'S AFFAIRS
Mailing Address - City:BELLEVUE
Mailing Address - State:KY
Mailing Address - Zip Code:41073
Mailing Address - Country:US
Mailing Address - Phone:859-392-3840
Mailing Address - Fax:859-392-3841
Practice Address - Street 1:103 LANDMARK DRIVE STE 300
Practice Address - Street 2:DEPARTMENT OF VETERAN'S AFFAIRS
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073
Practice Address - Country:US
Practice Address - Phone:859-392-3840
Practice Address - Fax:859-392-3841
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-19591041C0700X
KYKY-03-0095106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist