Healthcare Provider Details

I. General information

NPI: 1801211891
Provider Name (Legal Business Name): ANDREA TRUJILLO I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 E BONANZA SUITE 160-A
LAS VEGAS NV
89101
US

IV. Provider business mailing address

3020 E BONANZA RD
LAS VEGAS NV
89101-3702
US

V. Phone/Fax

Practice location:
  • Phone: 702-771-9128
  • Fax: 702-982-3069
Mailing address:
  • Phone: 702-771-9128
  • Fax: 702-982-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number20131063992
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: