Provider Demographics
NPI:1811269608
Name:SANDOVAL, PRESTON (COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 79 BOX 1510
Mailing Address - Street 2:
Mailing Address - City:OJO ENCINO
Mailing Address - State:NM
Mailing Address - Zip Code:87013-9612
Mailing Address - Country:US
Mailing Address - Phone:505-731-1505
Mailing Address - Fax:505-731-1502
Practice Address - Street 1:HC 79 BOX 1510
Practice Address - Street 2:
Practice Address - City:OJO ENCINO
Practice Address - State:NM
Practice Address - Zip Code:87013-9612
Practice Address - Country:US
Practice Address - Phone:505-731-1505
Practice Address - Fax:505-731-1502
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0089811101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)