Healthcare Provider Details

I. General information

NPI: 1356016752
Provider Name (Legal Business Name): ANDREA Y AYALA SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DAVI AVENUE
PITTSBURG CA
94565-3701
US

IV. Provider business mailing address

4167 RITA DR
MARTINEZ CA
94553-1435
US

V. Phone/Fax

Practice location:
  • Phone: 925-427-1384
  • Fax:
Mailing address:
  • Phone: 925-339-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: