MEDICARE: ANDREA ALICIA GAMBOZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	101YM0800X	Mental Health Counselor
3	1041C0700X	Clinical Social Worker	137364	CA

General Provider Information

NPI Number	:	1063131829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA ALICIA GAMBOZ

Provider Business Mailing Address
First Line	:	PO BOX 672
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-0672
Country	:	US
Telephone Number	:	562-645-3199
Fax Number	:

Provider Business Practice Location Address
First Line	:	18411 CRENSHAW BLVD
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90504-5042
Country	:	US
Telephone Number	:	562-645-3199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2022
Last Update Date	:	03/09/2026

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