Provider Demographics
NPI:1902595978
Name:SANDOVAL, MARLENE JEANETTE (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:JEANETTE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ABBOTT DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-4323
Mailing Address - Country:US
Mailing Address - Phone:484-255-3822
Mailing Address - Fax:
Practice Address - Street 1:700 ABBOTT DR STE 2
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-4323
Practice Address - Country:US
Practice Address - Phone:484-255-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician