Healthcare Provider Details

I. General information

NPI: 1477782498
Provider Name (Legal Business Name): MRS. ANDREA MARIE BUBBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA MARIE MORA

II. Dates (important events)

Enumeration Date: 07/12/2009
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DUARTE RD
DUARTE CA
91010-3012
US

IV. Provider business mailing address

1500 DUARTE RD
DUARTE CA
91010-3012
US

V. Phone/Fax

Practice location:
  • Phone: 626-218-1202
  • Fax: 626-930-5331
Mailing address:
  • Phone: 626-218-1202
  • Fax: 626-930-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW68168
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: