Basic Information
| Provider Information | |||||||||
| NPI: | 1316462039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6513 197TH CT SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985798692 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 231 SE BARRINGTON DR STE 203 | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982773200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602400022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0133001214 | VA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 60777147 | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.