Healthcare Provider Details

I. General information

NPI: 1053878249
Provider Name (Legal Business Name): ANDREA MONIQUE SESSION CERT HAIR LOS SPECIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S MAIN ST
ORANGE CA
92868-4610
US

IV. Provider business mailing address

369 LAS PALMAS DR
IRVINE CA
92602-2313
US

V. Phone/Fax

Practice location:
  • Phone: 310-766-3378
  • Fax:
Mailing address:
  • Phone: 310-766-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberKK343445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: