Healthcare Provider Details

I. General information

NPI: 1962015677
Provider Name (Legal Business Name): ANDREW CALVIN HUDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 N D ST STE 700
SAN BERNARDINO CA
92401-1705
US

IV. Provider business mailing address

290 N D ST STE 700
SAN BERNARDINO CA
92401-1705
US

V. Phone/Fax

Practice location:
  • Phone: 909-963-5355
  • Fax:
Mailing address:
  • Phone: 909-963-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number97209
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number97209
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number132365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: