Provider Demographics
NPI:1801411079
Name:SANDOVAL, GREGORY CRAIG
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CRAIG
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:PO BOX 4751
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-0023
Mailing Address - Country:US
Mailing Address - Phone:916-280-4678
Mailing Address - Fax:208-518-1286
Practice Address - Street 1:7520 S SHINGLE RD
Practice Address - Street 2:
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8081
Practice Address - Country:US
Practice Address - Phone:916-280-4678
Practice Address - Fax:208-518-1286
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician