Provider Demographics
NPI:1942898341
Name:SANDOVAL, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
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 1:122 BLACK MESA UNIT 4188
Mailing Address - Street 2:
Mailing Address - City:ALGODONES
Mailing Address - State:NM
Mailing Address - Zip Code:87001-8119
Mailing Address - Country:US
Mailing Address - Phone:970-234-5112
Mailing Address - Fax:
Practice Address - Street 1:8 RIVERSIDE RD
Practice Address - Street 2:
Practice Address - City:ALGODONES
Practice Address - State:NM
Practice Address - Zip Code:87001-5033
Practice Address - Country:US
Practice Address - Phone:970-234-5112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician