Provider Demographics
NPI:1912513003
Name:SANDOVAL, VANESSA RENEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENEE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16465 HARMS WAY
Mailing Address - Street 2:
Mailing Address - City:PINEY POINT
Mailing Address - State:MD
Mailing Address - Zip Code:20674-3314
Mailing Address - Country:US
Mailing Address - Phone:304-771-7086
Mailing Address - Fax:
Practice Address - Street 1:46060 MILLSTONE LANDING RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-2149
Practice Address - Country:US
Practice Address - Phone:301-863-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09919235Z00000X
MD02161L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty