Provider Demographics
NPI:1447144738
Name:SANDOVAL, KELLY MICHELLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
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 1:45 E VALLEY STREAM BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6317
Mailing Address - Country:US
Mailing Address - Phone:516-937-8086
Mailing Address - Fax:
Practice Address - Street 1:16318 JAMAICA AVE STE 2
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4901
Practice Address - Country:US
Practice Address - Phone:516-937-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker