Provider Demographics
NPI:1841064433
Name:SANDOVAL, RUDI OMAR
Entity type:Individual
Prefix:
First Name:RUDI
Middle Name:OMAR
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUDI
Other - Middle Name:OMAR
Other - Last Name:RIVERA SANDOVAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1919 LAZY LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-3034
Mailing Address - Country:US
Mailing Address - Phone:713-884-0132
Mailing Address - Fax:
Practice Address - Street 1:1919 LAZY LN
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77489-3034
Practice Address - Country:US
Practice Address - Phone:713-884-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical