Provider Demographics
NPI:1194202085
Name:MOSQUEDA, ANDREA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:MOSQUEDA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4217 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4944
Mailing Address - Country:US
Mailing Address - Phone:773-340-1321
Mailing Address - Fax:
Practice Address - Street 1:4217 W 59TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:773-340-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010614103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty