=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508533191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVELYN ANDRADE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2021
-----------------------------------------------------
Last Update Date | 08/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 253 N SAN GABRIEL BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-844-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2858 NANDINA DR
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93550-5948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-537-1439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------