Provider Demographics
NPI:1831961366
Name:SANDOVAL, KELLY (CAS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 S VALENTIA ST UNIT 85
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-6815
Mailing Address - Country:US
Mailing Address - Phone:303-564-1868
Mailing Address - Fax:
Practice Address - Street 1:1011 S VALENTIA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-6812
Practice Address - Country:US
Practice Address - Phone:303-564-1868
Practice Address - Fax:303-393-8637
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0021042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)