Provider Demographics
NPI:1790428027
Name:SANDOVAL, AUDREY ALEXA
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ALEXA
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 1:29951 W AVALON DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3180
Mailing Address - Country:US
Mailing Address - Phone:623-297-9172
Mailing Address - Fax:
Practice Address - Street 1:29951 W AVALON DR
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-3180
Practice Address - Country:US
Practice Address - Phone:623-297-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA135902355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLPA13590Medicaid