Provider Demographics
NPI:1821550567
Name:SANDOVAL, STEPHANIE RAYLINE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAYLINE
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 1:1958 2ND AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8314
Mailing Address - Country:US
Mailing Address - Phone:619-991-0849
Mailing Address - Fax:
Practice Address - Street 1:1958 2ND AVE APT 408
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-8314
Practice Address - Country:US
Practice Address - Phone:619-991-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106449106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist