Basic Information
| Provider Information | |||||||||
| NPI: | 1104178532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDRADE | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602466336 | ||||||||
| FaxNumber: | 7609460819 | ||||||||
| Practice Location | |||||||||
| Address1: | 17800 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923071221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602466336 | ||||||||
| FaxNumber: | 7609460819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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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 | 1041C0700X | 29464 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.