Healthcare Provider Details

I. General information

NPI: 1942052469
Provider Name (Legal Business Name): ANDREW JOSEPH PROCHAZKA AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 06/27/2025
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23041 AVENIDA DE LA CARLOTA FL 4
LAGUNA HILLS CA
92653-1511
US

IV. Provider business mailing address

2437 DUKE PL
COSTA MESA CA
92626-6313
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-6480
  • Fax:
Mailing address:
  • Phone: 949-600-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: