Provider Demographics
NPI:1093050718
Name:CARRUTH, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CARRUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 N CALIFORNIA ST STE B
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-463-0870
Mailing Address - Fax:209-463-1803
Practice Address - Street 1:1947 N CALIFORNIA ST STE B
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6029
Practice Address - Country:US
Practice Address - Phone:209-463-0870
Practice Address - Fax:209-463-1803
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)