Provider Demographics
NPI:1841043361
Name:SANDOVAL, SAMANTHA OLIVIA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:OLIVIA
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 1:5717 OLD COLONY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6956
Mailing Address - Country:US
Mailing Address - Phone:702-481-5514
Mailing Address - Fax:
Practice Address - Street 1:1920 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3635
Practice Address - Country:US
Practice Address - Phone:702-608-5763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT4179106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician