Provider Demographics
NPI:1124586813
Name:CONANAN, ANDREA KAMILLE (MS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:KAMILLE
Last Name:CONANAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CAMINO DEL RIO S
Mailing Address - Street 2:STE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3505
Mailing Address - Country:US
Mailing Address - Phone:619-578-3623
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S
Practice Address - Street 2:STE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3505
Practice Address - Country:US
Practice Address - Phone:619-578-3623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5241101YM0800X
CA13059101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional