Healthcare Provider Details

I. General information

NPI: 1558214205
Provider Name (Legal Business Name): DEREK ANDRUCKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 MARIA LN STE 240
WALNUT CREEK CA
94596-5399
US

IV. Provider business mailing address

507 CAULFIELD CT
CLAYTON CA
94517-1006
US

V. Phone/Fax

Practice location:
  • Phone: 510-694-4359
  • Fax:
Mailing address:
  • Phone: 925-222-0628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number145358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: