Healthcare Provider Details

I. General information

NPI: 1194241141
Provider Name (Legal Business Name): STEFANY ANDY CAHYADI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W 25TH AVE STE 200
SAN MATEO CA
94403-2208
US

IV. Provider business mailing address

3800 COOLIDGE AVE
OAKLAND CA
94602-3311
US

V. Phone/Fax

Practice location:
  • Phone: 650-286-2090
  • Fax:
Mailing address:
  • Phone: 510-485-5210
  • Fax: 510-842-0406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: