Provider Demographics
NPI:1073277240
Name:DE ANDA, ANGEL SAMUEL
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:SAMUEL
Last Name:DE ANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24077 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8519
Mailing Address - Country:US
Mailing Address - Phone:530-265-9057
Mailing Address - Fax:
Practice Address - Street 1:1848 WILLOW PASS RD STE 207
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2542
Practice Address - Country:US
Practice Address - Phone:530-265-9057
Practice Address - Fax:530-292-3803
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner