Basic Information
| Provider Information | |||||||||
| NPI: | 1497398317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2661 NE CARRIAGE LN | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977548435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089199099 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1103 NE ELM ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2019 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.