Provider Demographics
NPI:1912774696
Name:SANDOVAL, NICHOLE CRISTINE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CRISTINE
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 1:3006 BRILLANTE
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3806
Mailing Address - Country:US
Mailing Address - Phone:949-302-7309
Mailing Address - Fax:
Practice Address - Street 1:555 PARKCENTER DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3521
Practice Address - Country:US
Practice Address - Phone:949-302-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician