Healthcare Provider Details

I. General information

NPI: 1861035586
Provider Name (Legal Business Name): ANDREA MN PERKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA MARGARET NICOLE PERKINS

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SJC BHS BACOP 1149 EL DORADO STREET
STOCKTON CA
95202
US

IV. Provider business mailing address

SJC BHS BACOP 1149 EL DORADO STREET
STOCKTON CA
95202
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-2337
  • Fax: 209-953-7400
Mailing address:
  • Phone: 209-468-2337
  • Fax: 209-953-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number69571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: