Derik L Sandoval, SUDPT

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

CO60987238 Issued in WA

Practice address

2700 Simpson Ave
Suite 101
Aberdeen, WA 98520

Phone

(360) 612-0012

Fax

(360) 532-0670

NPI assigned

Sep 7, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Columbia Wellness

  • Case Management Agency
  • Longview, WA
  • NPI 1487659579
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1599436800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620172800000",
    "number": "1174137152",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1847",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "98632",
            "telephone_number": "360-234-0203",
            "fax_number": "360-577-0269"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2700 SIMPSON AVE",
            "address_2": "SUITE 101",
            "city": "ABERDEEN",
            "state": "WA",
            "postal_code": "98520",
            "telephone_number": "360-612-0012",
            "fax_number": "360-532-0670"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SANDOVAL",
        "first_name": "DERIK",
        "middle_name": "L",
        "name_prefix": "Mr.",
        "credential": "SUDPT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-09-07",
        "last_updated": "2021-05-05",
        "certification_date": "2021-05-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "WA",
            "license": "CO60987238",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2077844",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Addiction (Substance Use Disorder) Counselor in Aberdeen, WA
• Providers in Aberdeen, WA by specialty
• Addiction (Substance Use Disorder) Counselor in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.