Provider Demographics
NPI:1710722558
Name:SANDOVAL, PHILLIP PAUL
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PAUL
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9234 E 108TH PL
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7532
Mailing Address - Country:US
Mailing Address - Phone:303-450-9440
Mailing Address - Fax:
Practice Address - Street 1:9234 E 108TH PL
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80640-7532
Practice Address - Country:US
Practice Address - Phone:303-450-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor