Provider Demographics
NPI:1093192874
Name:TABUENCA, ANDREA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:TABUENCA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:LEWALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1804 EMBARCADERO RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 QUARRY RD
Practice Address - Street 2:MC 5719
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1419
Practice Address - Country:US
Practice Address - Phone:650-498-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103TC2200X103TC2200X
CAPSY28819103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent