Healthcare Provider Details

I. General information

NPI: 1942921648
Provider Name (Legal Business Name): MR. ANDREW DEAN KRASKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 PALM AVE
SAN MATEO CA
94403-1814
US

IV. Provider business mailing address

2251 PALM AVE
SAN MATEO CA
94403-1814
US

V. Phone/Fax

Practice location:
  • Phone: 650-513-6500
  • Fax:
Mailing address:
  • Phone: 650-513-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: